Healthcare Provider Details

I. General information

NPI: 1104070945
Provider Name (Legal Business Name): THERESA EDOBOR-WHISKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 EDSON AVE
BRONX NY
10469-2609
US

IV. Provider business mailing address

3440 EDSON AVE
BRONX NY
10469-2609
US

V. Phone/Fax

Practice location:
  • Phone: 646-228-6209
  • Fax:
Mailing address:
  • Phone: 646-228-6209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number638068
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: