Healthcare Provider Details

I. General information

NPI: 1770903148
Provider Name (Legal Business Name): SWADA IDDRIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 WILLIAMSBRIDGE RD
BRONX NY
10461-2507
US

IV. Provider business mailing address

1434 WILLIAMSBRIDGE RD
BRONX NY
10461-2507
US

V. Phone/Fax

Practice location:
  • Phone: 718-618-0401
  • Fax:
Mailing address:
  • Phone: 718-618-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number682460
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF421449
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: