Provider Demographics
NPI:1295869055
Name:ANDERSON, JOELLEN (NP)
Entity type:Individual
Prefix:MS
First Name:JOELLEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2131
Mailing Address - Country:US
Mailing Address - Phone:516-783-1947
Mailing Address - Fax:
Practice Address - Street 1:4 PHYLLIS DR
Practice Address - Street 2:STE H
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2900
Practice Address - Country:US
Practice Address - Phone:631-447-7560
Practice Address - Fax:631-774-7561
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400410363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY164773OtherVALUE OPTIONS GOV'T
NY7482405OtherVALUE OPTIONS
NY164773OtherVALUE OPTIONS GOV'T