Healthcare Provider Details

I. General information

NPI: 1104736867
Provider Name (Legal Business Name): VIVIAN UGWU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 ELDERT LN APT 5S
BROOKLYN NY
11208-4736
US

IV. Provider business mailing address

790 ELDERT LN APT 5S
BROOKLYN NY
11208-4736
US

V. Phone/Fax

Practice location:
  • Phone: 631-829-9824
  • Fax:
Mailing address:
  • Phone: 631-829-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number356380
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: