Provider Demographics
NPI:1861903759
Name:ALTIDORT, MIREILLE (RN)
Entity type:Individual
Prefix:MS
First Name:MIREILLE
Middle Name:
Last Name:ALTIDORT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 1ST AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1106
Practice Address - Country:US
Practice Address - Phone:845-680-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330047164W00000X
NY819496163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No164W00000XNursing Service ProvidersLicensed Practical Nurse