Healthcare Provider Details

I. General information

NPI: 1104176874
Provider Name (Legal Business Name): EVELINA ALTAGRACIA URENA MS.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LAFAYETTE AVE BASEMENT
BROOKLYN NY
11217-1434
US

IV. Provider business mailing address

25 LAFAYETTE AVE BASEMENT
BROOKLYN NY
11217-1434
US

V. Phone/Fax

Practice location:
  • Phone: 718-450-1526
  • Fax:
Mailing address:
  • Phone: 718-450-1526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number621525
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: