Healthcare Provider Details

I. General information

NPI: 1750644332
Provider Name (Legal Business Name): JEANETTE MICHELLE STEWART BA, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W 16TH RD
BROAD CHANNEL NY
11693-1206
US

IV. Provider business mailing address

60 W 16TH RD
BROAD CHANNEL NY
11693-1206
US

V. Phone/Fax

Practice location:
  • Phone: 718-344-9078
  • Fax:
Mailing address:
  • Phone: 718-344-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: