Provider Demographics
NPI:1750868824
Name:WINTJEN, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WINTJEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 NOYAC RD
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-1919
Mailing Address - Country:US
Mailing Address - Phone:256-283-2592
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4897
Practice Address - Country:US
Practice Address - Phone:631-687-4153
Practice Address - Fax:631-687-4282
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339924363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily