Provider Demographics
NPI:1518376789
Name:CLYDE, JOANNE ELAINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:ELAINE
Last Name:CLYDE
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 1:3119 BEECHNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1769
Mailing Address - Country:US
Mailing Address - Phone:631-475-7842
Mailing Address - Fax:631-444-9337
Practice Address - Street 1:STONY BROOK MEDICAL CTR
Practice Address - Street 2:101 NICOLLS ROAD
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2903
Practice Address - Fax:631-444-9337
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306686363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health