Provider Demographics
NPI:1427243799
Name:MICHAILIDES, SALLY MICHELLE (FNP)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:MICHELLE
Last Name:MICHAILIDES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:MICHELLE
Other - Last Name:MICHAILIDES-TWONSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:71 PROSPECT AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2907
Mailing Address - Country:US
Mailing Address - Phone:518-943-1404
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-943-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY396158-1163WC0200X
NYF336227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01464488Medicaid