Provider Demographics
NPI:1689632622
Name:FANELLI, CHRISTINE ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:ANN
Last Name:FANELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7381
Mailing Address - Country:US
Mailing Address - Phone:631-581-4400
Mailing Address - Fax:631-581-2564
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7381
Practice Address - Country:US
Practice Address - Phone:631-581-4400
Practice Address - Fax:631-581-2564
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02167655Medicaid
NY1202G1Medicare PIN
NY02167655Medicaid