Healthcare Provider Details

I. General information

NPI: 1881969624
Provider Name (Legal Business Name): JUDITH SMALLS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 HARING ST
BROOKLYN NY
11235-1655
US

IV. Provider business mailing address

2525 HARING ST
BROOKLYN NY
11235-1655
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-6984
  • Fax: 718-648-7816
Mailing address:
  • Phone: 718-769-6984
  • Fax: 718-648-7816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number303407
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: