Provider Demographics
NPI:1255523973
Name:BOEHM, DONNA LEE (ANP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LEE
Last Name:BOEHM
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:45 RESEARCH WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-638-3240
Mailing Address - Fax:631-350-7143
Practice Address - Street 1:1320 STONY BROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2222
Practice Address - Country:US
Practice Address - Phone:631-941-2273
Practice Address - Fax:631-941-2501
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303323-01363LA2200X
NY327948364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05459889Medicaid