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General NPI Number Information
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NPI Number | 1306043351
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Entity Type | Individual
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Provider Name | COLLEEN MARY DEFALCO NP
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Gender | Female
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | VA MEDICAL CENTER, DEPT OF GASTROENTEROLOGY 79 MIDDLEVILLE ROAD
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City | NORTHPORT
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State | NY
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Zip | 11768-2290
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Country | US
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Telephone | 631-261-4400
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Fax | 631-486-6113
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Provider Business Mailing Address
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Address Line | 17 COLONIAL DR
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City | SMITHTOWN
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State | NY
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Zip | 11787-4212
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Country | US
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Telephone | 631-864-7279
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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 | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | F300698-1
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License Number State | NY
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