Provider Demographics
NPI:1306941026
Name:BANOVICH, ROSALIE (NPP)
Entity type:Individual
Prefix:
First Name:ROSALIE
Middle Name:
Last Name:BANOVICH
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ROCKLEDGE DR.
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967
Mailing Address - Country:US
Mailing Address - Phone:631-445-6881
Mailing Address - Fax:631-729-3484
Practice Address - Street 1:565 ROUTE 25A STE 209
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2600
Practice Address - Country:US
Practice Address - Phone:631-445-6881
Practice Address - Fax:631-849-4926
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400724363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF400724OtherPSYCH NURSE PRACT. LIC
NY330804OtherREGISTERED NURSE
NY330804OtherREGISTERED NURSE
NYF400724OtherPSYCH NURSE PRACT. LIC