Provider Demographics
NPI:1598230914
Name:DEPTA, MICHELLE MARY
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARY
Last Name:DEPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SOUTH ST APT 3D
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-2272
Mailing Address - Country:US
Mailing Address - Phone:516-754-6609
Mailing Address - Fax:
Practice Address - Street 1:127 SOUTH ST APT 3D
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2272
Practice Address - Country:US
Practice Address - Phone:516-754-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist