Provider Demographics
NPI:1700623907
Name:SUPERSAD COLEY, TITSANIA ELIZABETH (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:TITSANIA
Middle Name:ELIZABETH
Last Name:SUPERSAD COLEY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 ISLIP AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-1808
Mailing Address - Country:US
Mailing Address - Phone:631-277-8804
Mailing Address - Fax:
Practice Address - Street 1:25 SCHOENFELD BLVD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2982
Practice Address - Country:US
Practice Address - Phone:631-807-0085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311883363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health