Provider Demographics
NPI:1538224654
Name:MCKEON-SIMONE, MAUREEN (RD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MCKEON-SIMONE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LANIER LN
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 SMITH HAVEN MALL
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1219
Practice Address - Country:US
Practice Address - Phone:641-444-1933
Practice Address - Fax:631-444-7248
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY2600133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9225E1Medicare UPIN