Healthcare Provider Details

I. General information

NPI: 1114877545
Provider Name (Legal Business Name): NANA BOATENG AGYENIM FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 INWOOD AVE
BRONX NY
10452-2001
US

IV. Provider business mailing address

1543 INWOOD AVE
BRONX NY
10452-2001
US

V. Phone/Fax

Practice location:
  • Phone: 347-456-9310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number844008
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number358891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: