Provider Demographics
NPI:1992231435
Name:AGNELLO, CARISSA LYNN
Entity type:Individual
Prefix:MS
First Name:CARISSA
Middle Name:LYNN
Last Name:AGNELLO
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 1:16 LARCH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4460
Mailing Address - Country:US
Mailing Address - Phone:631-484-8920
Mailing Address - Fax:
Practice Address - Street 1:583 BROADHOLLOW RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-5017
Practice Address - Country:US
Practice Address - Phone:631-484-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY851929141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist