Healthcare Provider Details

I. General information

NPI: 1437332830
Provider Name (Legal Business Name): OMANA KURUVILLA FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 01/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 E 22ND ST #1C HEALTHWAY MEDICAL PC IRINA LELCHUK MD DO
BROOKLYN NY
11229-3602
US

IV. Provider business mailing address

186 GRAVES STREET
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-648-4545
  • Fax: 718-648-7788
Mailing address:
  • Phone: 718-982-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF333300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: