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General NPI Number Information
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NPI Number | 1275204778
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Entity Type | Individual
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Provider Name | MATTHEW G KILLIAN PMHNP
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Gender | Male
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Dates
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Enumeration Date | 09/23/2021
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 200 BROADHOLLOW RD STE 119
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City | MELVILLE
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State | NY
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Zip | 11747-4846
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Country | US
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Telephone | 516-588-7512
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Fax |
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Provider Business Mailing Address
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Address Line | 121 APPLE ST
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City | BRENTWOOD
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State | NY
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Zip | 11717-7214
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Country | US
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Telephone | 732-939-6463
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 403593
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License Number State | NY
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