Healthcare Provider Details

I. General information

NPI: 1790964278
Provider Name (Legal Business Name): SIOBHAN MARIE POLESE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE
BRONX NY
10467-2403
US

IV. Provider business mailing address

111 E 210TH ST ROSENTHAL 4
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2342
  • Fax:
Mailing address:
  • Phone: 718-741-2487
  • Fax: 718-920-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number381531
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: