Provider Demographics
NPI:1912549049
Name:CAZAUBON, KETTLY
Entity Type:Individual
Prefix:
First Name:KETTLY
Middle Name:
Last Name:CAZAUBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:567 MILLER AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-6310
Practice Address - Country:US
Practice Address - Phone:917-548-8917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405633363LP0808X
NY345151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health