Provider Demographics
NPI:1568958700
Name:NURSE PRACTITIONER INFANT AND CHILD HEALTHCARE, PC
Entity Type:Organization
Organization Name:NURSE PRACTITIONER INFANT AND CHILD HEALTHCARE, PC
Other - Org Name:MICHELE KELLY LPNP, NPP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRIOLO
Authorized Official - Suffix:
Authorized Official - Credentials:LPNP, NPP
Authorized Official - Phone:631-235-2401
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764
Mailing Address - Country:US
Mailing Address - Phone:631-235-2401
Mailing Address - Fax:631-689-3993
Practice Address - Street 1:1227 MAIN STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-235-2401
Practice Address - Fax:631-689-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380749363LP0200X
NYF-400866-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty