Basic Information
| Provider Information | |||||||||
| NPI: | 1285075804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LY | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440650 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 N BELLE MEAD RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314444630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 648293 | NY | N | Nursing Service Providers | Registered Nurse | Pediatrics | 208000000X | 382766 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.