Provider Demographics
NPI:1710415088
Name:FARRELL, JILL (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FARRELL
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 1:8 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3506
Mailing Address - Country:US
Mailing Address - Phone:1917-209-0595
Mailing Address - Fax:
Practice Address - Street 1:1743 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2649
Practice Address - Country:US
Practice Address - Phone:631-758-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily