Basic Information
| Provider Information | |||||||||
| NPI: | 1124340641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHIATRIC NURSE PRACTITIONER SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5036 JERICHO TURNPIKE | ||||||||
| Address2: | |||||||||
| City: | NORTHPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314625222 | ||||||||
| FaxNumber: | 6314625258 | ||||||||
| Practice Location | |||||||||
| Address1: | 5036 JERICHO TURNPIKE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | NORTHPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314625222 | ||||||||
| FaxNumber: | 6314625258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2010 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHIATRIC NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 6318487104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 363LP0808X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.