Healthcare Provider Details

I. General information

NPI: 1417460130
Provider Name (Legal Business Name): OTILIA MACIAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 KINGSBRIDGE AVE
BRONX NY
10463-4016
US

IV. Provider business mailing address

3425 KINGSBRIDGE AVE APT 704
BRONX NY
10463-4000
US

V. Phone/Fax

Practice location:
  • Phone: 210-638-1032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number728868-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: