Provider Demographics
NPI:1457921090
Name:BYRNE, NICOLE LYN (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:BYRNE
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3551
Mailing Address - Country:US
Mailing Address - Phone:631-921-6283
Mailing Address - Fax:
Practice Address - Street 1:2539 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3551
Practice Address - Country:US
Practice Address - Phone:631-737-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717252163WP0808X
NY403641363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health