Healthcare Provider Details

I. General information

NPI: 1598087363
Provider Name (Legal Business Name): SUSAN MARTELLO-GILL MSN, FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN MARTELLO MSN, FNP, PMHNP

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 WANTAGH AVE
WANTAGH NY
11793-2204
US

IV. Provider business mailing address

623 STEWART AVE
GARDEN CITY NY
11530-4771
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-2123
  • Fax:
Mailing address:
  • Phone: 516-741-0055
  • Fax: 516-745-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF381822-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF381822-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberF381822
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401234
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: