Provider Demographics
NPI:1972656783
Name:PROVOST, PHYLLIS (APRN)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3608
Mailing Address - Country:US
Mailing Address - Phone:631-724-5522
Mailing Address - Fax:631-724-5546
Practice Address - Street 1:750 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2943
Practice Address - Country:US
Practice Address - Phone:631-724-5522
Practice Address - Fax:631-724-5546
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270668-1163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health