Provider Demographics
NPI:1366761009
Name:DITTLER, AMY C (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:C
Last Name:DITTLER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:C
Other - Last Name:MACCHIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:282 AUBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1734
Mailing Address - Country:US
Mailing Address - Phone:917-385-9195
Mailing Address - Fax:
Practice Address - Street 1:450 WAVERLY AVE
Practice Address - Street 2:STE 11
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1555
Practice Address - Country:US
Practice Address - Phone:917-385-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY639551163WP0808X
NYF402005363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health