Healthcare Provider Details

I. General information

NPI: 1043402357
Provider Name (Legal Business Name): NIYA WANICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 ENGLE ST SUITE 101
ENGLEWOOD NJ
07631-2444
US

IV. Provider business mailing address

216 ENGLE STREET SUITE 101
ENGLEWOOD NJ
07631
US

V. Phone/Fax

Practice location:
  • Phone: 201-816-9800
  • Fax: 201-567-1569
Mailing address:
  • Phone: 201-816-9800
  • Fax: 201-567-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number230693
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number104650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: