Healthcare Provider Details

I. General information

NPI: 1902890502
Provider Name (Legal Business Name): BARBARA RUSSELL WILDFEIR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PELHAM PKWY S
BRONX NY
10461-1100
US

IV. Provider business mailing address

15 CHESHIRE ST
HUNTINGTON STATION NY
11746-1214
US

V. Phone/Fax

Practice location:
  • Phone: 718-730-1004
  • Fax: 718-892-6469
Mailing address:
  • Phone: 631-549-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF-333377-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: