Healthcare Provider Details

I. General information

NPI: 1154639466
Provider Name (Legal Business Name): KENISHA ROXANNE LYTTLETON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E 141 ST
BRONX NY
10454
US

IV. Provider business mailing address

615 E 141 ST
BRONX NY
10454
US

V. Phone/Fax

Practice location:
  • Phone: 347-845-9465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number342101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: