Provider Demographics
NPI:1699088955
Name:MACCHIO, PHYLLIS (NP)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:MACCHIO
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:PO BOX 5120
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1102
Mailing Address - Country:US
Mailing Address - Phone:631-331-1546
Mailing Address - Fax:
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300768-1 NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health