Provider Demographics
NPI:1629499199
Name:MINNIEFIELD, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MINNIEFIELD
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 1:2 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4164
Mailing Address - Country:US
Mailing Address - Phone:845-368-4700
Mailing Address - Fax:
Practice Address - Street 1:2 EXECUTIVE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4164
Practice Address - Country:US
Practice Address - Phone:845-368-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical