Healthcare Provider Details

I. General information

NPI: 1902928229
Provider Name (Legal Business Name): MICHELLE M WRUCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 MONTAUK HWY
WATER MILL NY
11976-2635
US

IV. Provider business mailing address

8 DREW DR
EASTPORT NY
11941-1335
US

V. Phone/Fax

Practice location:
  • Phone: 631-726-8033
  • Fax: 631-726-8031
Mailing address:
  • Phone: 631-325-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF380554-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: