1396607040 NPI number — PHOENIX NURSE PRACTITIONERS IN PSYCHIATRY, PLLC

Table of content: (NPI 1396607040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396607040 NPI number — PHOENIX NURSE PRACTITIONERS IN PSYCHIATRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX NURSE PRACTITIONERS IN PSYCHIATRY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1396607040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 BAYLOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-986-0388
Provider Business Mailing Address Fax Number:
866-598-0217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
732 SMITHTOWN BYP STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787-5020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-986-0388
Provider Business Practice Location Address Fax Number:
866-598-0217
Provider Enumeration Date:
12/02/2025

Additional Information

Authorized Official

Authorized Official Last Name:
DESIMONE
Authorized Official First Name:
JANINE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
631-921-1949

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com