Provider Demographics
NPI:1326461971
Name:RESERVE, MICAELLE
Entity Type:Individual
Prefix:
First Name:MICAELLE
Middle Name:
Last Name:RESERVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 CLINTON STREET
Mailing Address - Street 2:
Mailing Address - City:HEAMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550
Mailing Address - Country:US
Mailing Address - Phone:516-933-0485
Mailing Address - Fax:516-933-1923
Practice Address - Street 1:50 CLINTON ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4281
Practice Address - Country:US
Practice Address - Phone:516-933-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY776983163WH0200X
NY317658-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse