Active NPI
Noelle Anne Daversa
- Specialist
- Smithtown, NY
National Provider Identifier
1619367778
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- 2233020
- Practice address
- 208 Holly Lane
Smithtown, NY 11787 - Phone
- (631) 774-8665
- NPI assigned
- Jan 28, 2015
- Last updated
- Jan 28, 2015
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 2233020 | NY | Primary |
Addresses
Primary practice location
208 Holly Lane
Smithtown, NY 11787
Mailing address
208 Holly Lane
Smithtown, NY 11787
Phone (631) 774-8665
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2238079 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2233020 | NY | MD | Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1422403200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1422403200000",
"number": "1619367778",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "208 HOLLY LANE",
"city": "SMITHTOWN",
"state": "NY",
"postal_code": "11787",
"telephone_number": "631-774-8665"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "208 HOLLY LANE",
"city": "SMITHTOWN",
"state": "NY",
"postal_code": "11787",
"telephone_number": "631-774-8665"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DAVERSA",
"first_name": "NOELLE",
"middle_name": "ANNE",
"name_prefix": "Ms.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2015-01-28",
"last_updated": "2015-01-28",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "NY",
"license": "2233020",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2238079",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Smithtown, NY
- Danzi & Hajduk-Bennett Pediatrics PLLC (Commack Pediatric Partners)
- Stephania Daneica Darbonne
- Debra Diane Darienzo, RN
- Gabrielle Darnaby, MSW
- Lauren Darvas
- David M. Shobin, MD,Women's Health, PLLC
- David Michael Horowitz, MD PC
- David S Wiener DDS PC (Smithtown Dental Care)
- David S. Wiener D.D.S. & Robert L. Wagner DMD P.LL.C.
- Anne L Davis, LCSW
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.