Individual
KENNETH WILLIAM NISSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ANP
Contact information
Practice address
75 N COUNTRY RD, PORT JEFFERSON, NY 11777-2119
(631) 476-2786
Mailing address
25 WILTSHIRE DR, COMMACK, NY 11725-3330
(516) 521-0456
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
306258
NY
Other
Enumeration date
06/24/2013
Last updated
06/24/2013
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