Healthcare Provider Details

I. General information

NPI: 1003485335
Provider Name (Legal Business Name): VIVICA SUMRAJIT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 GRAND CONCOURSE
BRONX NY
10458-5203
US

IV. Provider business mailing address

9017 153RD ST
JAMAICA NY
11432-5974
US

V. Phone/Fax

Practice location:
  • Phone: 212-695-5122
  • Fax:
Mailing address:
  • Phone: 718-322-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number683460
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: