Provider Demographics
NPI:1518543602
Name:MOTT, REGINA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:MOTT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GREAT EAST NECK RD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8027
Mailing Address - Country:US
Mailing Address - Phone:631-422-4800
Mailing Address - Fax:631-422-6484
Practice Address - Street 1:134 GREAT EAST NECK RD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8027
Practice Address - Country:US
Practice Address - Phone:631-422-4800
Practice Address - Fax:631-422-6484
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY357218-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-4261026OtherREGINA MOTT