Healthcare Provider Details

I. General information

NPI: 1194629246
Provider Name (Legal Business Name): KWAME ATTA AMO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

42 PARK AVE APT B22
YONKERS NY
10703-3425
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4621
  • Fax:
Mailing address:
  • Phone: 718-920-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number361079
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: