Healthcare Provider Details

I. General information

NPI: 1548183056
Provider Name (Legal Business Name): MIA BACCHUS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 LINDEN BLVD
BROOKLYN NY
11226-3627
US

IV. Provider business mailing address

14312 184TH ST
SPRINGFIELD GARDENS NY
11413-3227
US

V. Phone/Fax

Practice location:
  • Phone: 718-462-2080
  • Fax:
Mailing address:
  • Phone: 347-869-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number852533
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: