Healthcare Provider Details

I. General information

NPI: 1205320769
Provider Name (Legal Business Name): LUCRECE BONOSTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 LIBERTY AVENUE
BROOKLYN NY
11208
US

IV. Provider business mailing address

211-02 75TH AVENUE APT # 6M
OAKLAND GARDENS NY
11364
US

V. Phone/Fax

Practice location:
  • Phone: 718-277-2700
  • Fax:
Mailing address:
  • Phone: 917-443-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341898-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: