Healthcare Provider Details

I. General information

NPI: 1316600190
Provider Name (Legal Business Name): GRACE WANGARI IRERI AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453-4303
US

IV. Provider business mailing address

2626 HALPERIN AVE
BRONX NY
10461-2631
US

V. Phone/Fax

Practice location:
  • Phone: 347-479-1303
  • Fax:
Mailing address:
  • Phone: 718-618-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG06210049
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG06210049
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG06210049
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: