Healthcare Provider Details

I. General information

NPI: 1306392592
Provider Name (Legal Business Name): MRS. DOMINIQUE EBONY PHINN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 BRYANT AVE
BRONX NY
10474-6006
US

IV. Provider business mailing address

730 BRYANT AVE
BRONX NY
10474-6006
US

V. Phone/Fax

Practice location:
  • Phone: 718-542-1537
  • Fax:
Mailing address:
  • Phone: 718-542-1537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP03319
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: