Provider Demographics
NPI:1891213997
Name:DARLY, DETTY (NP)
Entity Type:Individual
Prefix:MRS
First Name:DETTY
Middle Name:
Last Name:DARLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DETTY
Other - Middle Name:
Other - Last Name:PANICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:461 N GANNON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4317
Mailing Address - Country:US
Mailing Address - Phone:347-533-3834
Mailing Address - Fax:
Practice Address - Street 1:38 WINTHROP PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-727-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402271363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health