Provider Demographics
NPI:1598087363
Name:MARTELLO-GILL, SUSAN (MSN, FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARTELLO-GILL
Suffix:
Gender:F
Credentials:MSN, FNP, PMHNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MARTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, FNP, PMHNP
Mailing Address - Street 1:623 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4771
Mailing Address - Country:US
Mailing Address - Phone:516-741-0055
Mailing Address - Fax:516-745-8008
Practice Address - Street 1:1414 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2204
Practice Address - Country:US
Practice Address - Phone:516-221-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381822-1363L00000X, 363LF0000X
NYF381822364SP0200X
NY401234363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03385595Medicaid
NYG400325387Medicare PIN