Provider Demographics
NPI:1114097433
Name:WALSH, EILEEN (ANP)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E. MAIN STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-424-3787
Mailing Address - Fax:631-424-5868
Practice Address - Street 1:175 E. MAIN STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-424-3787
Practice Address - Fax:631-424-5868
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3521831363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health