Provider Demographics
NPI:1497291215
Name:ALLY, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 PATCHOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-3607
Mailing Address - Country:US
Mailing Address - Phone:631-926-6906
Mailing Address - Fax:
Practice Address - Street 1:134 PATCHOGUE AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-3607
Practice Address - Country:US
Practice Address - Phone:631-926-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3270721164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse