Provider Demographics
NPI:1326434309
Name:BUISSERETH, MONELLE (NP)
Entity Type:Individual
Prefix:
First Name:MONELLE
Middle Name:
Last Name:BUISSERETH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LOCUSTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1410
Mailing Address - Country:US
Mailing Address - Phone:516-270-2840
Mailing Address - Fax:
Practice Address - Street 1:38 LOCUSTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1410
Practice Address - Country:US
Practice Address - Phone:516-270-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8862962173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8862962OtherLICENSE