Provider Demographics
NPI:1083323307
Name:PERICONE, NAOMI ST CYR (NP)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:ST CYR
Last Name:PERICONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:ST CYR
Other - Last Name:PERICONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:818 MOTHER GASTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-7040
Mailing Address - Country:US
Mailing Address - Phone:718-938-7413
Mailing Address - Fax:
Practice Address - Street 1:104 W 40TH ST RM 416
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3617
Practice Address - Country:US
Practice Address - Phone:212-369-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404461363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty