Healthcare Provider Details

I. General information

NPI: 1558831867
Provider Name (Legal Business Name): ELITA WONG PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 08/11/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 BEDFORD AVE NO. 888
BROOKLYN NY
11211-4116
US

IV. Provider business mailing address

223 BEDFORD AVE NO. 888
BROOKLYN NY
11211-4116
US

V. Phone/Fax

Practice location:
  • Phone: 206-531-7844
  • Fax: 503-386-3252
Mailing address:
  • Phone: 206-531-7844
  • Fax: 503-386-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number674684
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number674684
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402711
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: