Provider Demographics
NPI:1598425977
Name:MAINGRETTE, WISELINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:WISELINE
Middle Name:
Last Name:MAINGRETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:WISELINE
Other - Middle Name:
Other - Last Name:KEROLLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1414 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF421309-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMM6948270OtherDEA