Basic Information
| Provider Information | |||||||||
| NPI: | 1104126408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKLEY | ||||||||
| FirstName: | JUSTINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 W MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | SAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117822540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315638190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 285 W MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | SAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117822540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315638190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | F-382150 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.