Healthcare Provider Details

I. General information

NPI: 1457088031
Provider Name (Legal Business Name): GLORIA YEBOAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 DECATUR AVE
BRONX NY
10458-4212
US

IV. Provider business mailing address

2665 DECATUR AVE
BRONX NY
10458-4212
US

V. Phone/Fax

Practice location:
  • Phone: 347-596-4551
  • Fax:
Mailing address:
  • Phone: 347-596-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number834425
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: