Provider Demographics
NPI:1871290205
Name:MICELI, DONNA (LMT)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:
Last Name:MICELI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEEDS BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1147
Mailing Address - Country:US
Mailing Address - Phone:631-645-0006
Mailing Address - Fax:
Practice Address - Street 1:640 BELLE TERRE RD BLDG J
Practice Address - Street 2:
Practice Address - City:PRT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-828-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
261Q00000XOther261Q00000X