Provider Demographics
NPI:1700636164
Name:HOMEGROWN ESSENTIAL WELLNESS PEDIATRICS & FAMILY.
Entity Type:Organization
Organization Name:HOMEGROWN ESSENTIAL WELLNESS PEDIATRICS & FAMILY.
Other - Org Name:HOMEGROWN ESSENTIAL WELLNESS PEDIATRICS & FAMILY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DNP
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:631-248-2700
Mailing Address - Street 1:257 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2807
Mailing Address - Country:US
Mailing Address - Phone:631-248-2700
Mailing Address - Fax:866-456-0906
Practice Address - Street 1:257 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2807
Practice Address - Country:US
Practice Address - Phone:631-248-2700
Practice Address - Fax:866-456-0906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty