Provider Demographics
NPI:1578709119
Name:CEO, MICHELLE L (CPNP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:CEO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:HSC T19-068 NICHOLS RD.
Mailing Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794
Mailing Address - Country:US
Mailing Address - Phone:631-444-2045
Mailing Address - Fax:631-444-8862
Practice Address - Street 1:HSC T19-068 NICHOLS RD.
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-2045
Practice Address - Fax:631-444-8862
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-04
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381993363LP0200X
NY381993363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics