Healthcare Provider Details

I. General information

NPI: 1841990363
Provider Name (Legal Business Name): KEISHA-MAE NICOLE RODRIGUEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

21 DAVENPORT AVE APT 3A
NEW ROCHELLE NY
10805-3427
US

V. Phone/Fax

Practice location:
  • Phone: 929-227-8131
  • Fax:
Mailing address:
  • Phone: 929-227-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number351553
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number734950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: