Healthcare Provider Details

I. General information

NPI: 1497301444
Provider Name (Legal Business Name): STEPHANIE ANGELA VAN ROSSEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28-18 ASTORIA BLVD, ASTORIA, NY 11102
ASTORIA NY
11102
US

IV. Provider business mailing address

9901 164TH AVE
HOWARD BEACH NY
11414-4009
US

V. Phone/Fax

Practice location:
  • Phone: 917-410-6905
  • Fax:
Mailing address:
  • Phone: 718-551-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number421399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: