Provider Demographics
NPI:1306043351
Name:DEFALCO, COLLEEN MARY (NP)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARY
Last Name:DEFALCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4212
Mailing Address - Country:US
Mailing Address - Phone:631-864-7279
Mailing Address - Fax:
Practice Address - Street 1:VA MEDICAL CENTER, DEPT OF GASTROENTEROLOGY
Practice Address - Street 2:79 MIDDLEVILLE ROAD
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2290
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:631-486-6113
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300698-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health