Provider Demographics
NPI:1396997672
Name:POULOS, CATHERINE (NP)
Entity type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:
Last Name:POULOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 W MONTAUK HWY STE 5
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3551
Mailing Address - Country:US
Mailing Address - Phone:631-495-3300
Mailing Address - Fax:631-822-2833
Practice Address - Street 1:332 W MONTAUK HWY STE 5
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3551
Practice Address - Country:US
Practice Address - Phone:631-495-3300
Practice Address - Fax:631-822-2833
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-401489363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0379L760Medicaid
NYA400108002Medicare UPIN