Provider Demographics
NPI:1790882397
Name:PENNISE, MIRIAM LEE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:LEE
Last Name:PENNISE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:MIRIAM
Other - Middle Name:LEE
Other - Last Name:DURAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:340 VETERANS HWY STE 12
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4300
Mailing Address - Country:US
Mailing Address - Phone:631-486-8400
Mailing Address - Fax:631-486-8080
Practice Address - Street 1:340 VETERANS HWY STE 12
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4300
Practice Address - Country:US
Practice Address - Phone:631-486-8400
Practice Address - Fax:631-486-8080
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301536 NP363LA2200X
NY379-297 RN363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY92N341Medicare ID - Type Unspecified
S91021Medicare UPIN