Provider Demographics
NPI:1669466488
Name:CACCAVANO, MICHELE HOLLY (ANP)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:HOLLY
Last Name:CACCAVANO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 EIMER ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1169
Mailing Address - Country:US
Mailing Address - Phone:631-444-6491
Mailing Address - Fax:631-444-9623
Practice Address - Street 1:3001 EXPRESSWAY DR N
Practice Address - Street 2:SUITE A
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5301
Practice Address - Country:US
Practice Address - Phone:631-444-6491
Practice Address - Fax:631-444-9623
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302258-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health