Provider Demographics
NPI:1043028665
Name:FORMICOLA, GEMMA ROBERTA
Entity type:Individual
Prefix:
First Name:GEMMA
Middle Name:ROBERTA
Last Name:FORMICOLA
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 1:3 CROSSON AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-2912
Mailing Address - Country:US
Mailing Address - Phone:516-567-6822
Mailing Address - Fax:
Practice Address - Street 1:400 S OYSTER BAY RD STE 102
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3500
Practice Address - Country:US
Practice Address - Phone:631-240-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist