Provider Demographics
NPI:1801132782
Name:RICKETTS, MARK A (PMHNP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 HERZEL BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-4234
Mailing Address - Country:US
Mailing Address - Phone:646-649-6840
Mailing Address - Fax:
Practice Address - Street 1:1565 HERZEL BLVD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-4234
Practice Address - Country:US
Practice Address - Phone:646-649-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF404433363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health