Healthcare Provider Details

I. General information

NPI: 1932418274
Provider Name (Legal Business Name): AGNES UMALI RUECA REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BALTIC STREET
BROOKLYN NY
11201
US

IV. Provider business mailing address

203 ELIZABETH ST
STATEN ISLAND NY
10310-2337
US

V. Phone/Fax

Practice location:
  • Phone: 718-855-3131
  • Fax:
Mailing address:
  • Phone: 718-876-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number361937-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: