Healthcare Provider Details

I. General information

NPI: 1669169140
Provider Name (Legal Business Name): MADELINE MEZA SIERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MANHATTAN CT
BROOKLYN NY
11223-6243
US

IV. Provider business mailing address

9 MANHATTAN CT
BROOKLYN NY
11223-6243
US

V. Phone/Fax

Practice location:
  • Phone: 347-309-2856
  • Fax:
Mailing address:
  • Phone: 347-309-2856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3119576
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: