Healthcare Provider Details

I. General information

NPI: 1609423821
Provider Name (Legal Business Name): KELLY HERAGHTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 MONTAUK HWY
WEST ISLIP NY
11795-4939
US

IV. Provider business mailing address

40 KINGFISHER RD
LEVITTOWN NY
11756-2130
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-0001
  • Fax:
Mailing address:
  • Phone: 516-395-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344263
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: