Provider Demographics
NPI:1558979377
Name:SOUTH SHORE PSYCHIATRIC NURSE PRACTITIONER GROUP
Entity Type:Organization
Organization Name:SOUTH SHORE PSYCHIATRIC NURSE PRACTITIONER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:TENNILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAITHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-400-9251
Mailing Address - Street 1:154 CHICHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-2004
Mailing Address - Country:US
Mailing Address - Phone:631-400-9251
Mailing Address - Fax:516-447-3403
Practice Address - Street 1:245 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8323
Practice Address - Country:US
Practice Address - Phone:631-771-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty