Provider Demographics
NPI:1457661969
Name:MARTOCCIA, PHYLISS A (NPP)
Entity Type:Individual
Prefix:
First Name:PHYLISS
Middle Name:A
Last Name:MARTOCCIA
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-427-1100
Mailing Address - Fax:
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-427-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401327-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health