Healthcare Provider Details

I. General information

NPI: 1114866803
Provider Name (Legal Business Name): ANGELA GRACE DE MESA BURNOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 BOSTON RD
BRONX NY
10460-4996
US

IV. Provider business mailing address

600 E 233RD ST STE 5N
BRONX NY
10466-2604
US

V. Phone/Fax

Practice location:
  • Phone: 718-842-8040
  • Fax:
Mailing address:
  • Phone: 718-920-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355904
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: