Basic Information
| Provider Information | |||||||||
| NPI: | 1346651049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCHESE | ||||||||
| FirstName: | CARMELA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 DRURY CT | ||||||||
| Address2: | |||||||||
| City: | HOLTSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117421015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316056104 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 682494-1 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 682494-1 | 05 | NY | MEDICAID |