Healthcare Provider Details

I. General information

NPI: 1710757265
Provider Name (Legal Business Name): REINA JOY MIZUKOSHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PKWY S
BRONX NY
10461-1138
US

IV. Provider business mailing address

1991 BROADWAY APT 12A
NEW YORK NY
10023-5827
US

V. Phone/Fax

Practice location:
  • Phone: 858-999-6050
  • Fax:
Mailing address:
  • Phone: 858-999-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number829659
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF383578
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: