Provider Demographics
NPI:1457767899
Name:PERGAMO, ANNETTE (PNP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:PERGAMO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:KOSIOROWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-4601
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD # T11-020
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1108
Practice Address - Country:US
Practice Address - Phone:631-444-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY671930163WP0200X
NY382510363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics