Provider Demographics
NPI:1386236941
Name:BACIGALUPO, KATIE
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:BACIGALUPO
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 1:21 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1958
Mailing Address - Country:US
Mailing Address - Phone:631-553-9339
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3015
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist