Provider Demographics
NPI:1235956095
Name:NIRAVATH, SIBIMOL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SIBIMOL
Middle Name:
Last Name:NIRAVATH
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4715
Mailing Address - Country:US
Mailing Address - Phone:631-456-1126
Mailing Address - Fax:
Practice Address - Street 1:1727 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2649
Practice Address - Country:US
Practice Address - Phone:631-654-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY406360363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health