1245009547 NPI number — MRS. CLAUDIA MIKE PROVENZALE AGNP

Table of content: MRS. CLAUDIA MIKE PROVENZALE AGNP (NPI 1245009547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245009547 NPI number — MRS. CLAUDIA MIKE PROVENZALE AGNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROVENZALE
Provider First Name:
CLAUDIA
Provider Middle Name:
MIKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245009547
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 NESCONSET HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONY BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11790-2555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-689-7899
Provider Business Mailing Address Fax Number:
631-689-7685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 NESCONSET HWY BLDG 11D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11790-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-689-7899
Provider Business Practice Location Address Fax Number:
631-689-7865
Provider Enumeration Date:
12/28/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  F310912-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com