Individual
MS. PHYLLIS PROVOST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
750 VETERANS HWY, HAUPPAUGE, NY 11788-2943
(631) 724-5522
(631) 724-5546
Mailing address
77 RIDGE RD, SOUTHAMPTON, NY 11968-3608
(631) 724-5522
(631) 724-5546
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
Primary
270668-1
NY
Other
Enumeration date
01/18/2007
Last updated
07/08/2007
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