Basic Information
| Provider Information | |||||||||
| NPI: | 1689097412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRADY | ||||||||
| FirstName: | KATIE LEIGH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440650 | ||||||||
| FaxNumber: | 6316384170 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 N BELLE MEAD RD | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442599 | ||||||||
| FaxNumber: | 6314441474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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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 | 363L00000X | 306512 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.