Provider Demographics
NPI:1033582291
Name:SELF EMPLOYED
Entity Type:Organization
Organization Name:SELF EMPLOYED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:KAITLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SYMANCYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-235-8057
Mailing Address - Street 1:67 RADBURN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 MILL DR
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-1403
Practice Address - Country:US
Practice Address - Phone:631-599-8372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705976-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility