Healthcare Provider Details

I. General information

NPI: 1922607514
Provider Name (Legal Business Name): SANDRA SEWANU AJIMAVO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 11/09/2025
Certification Date: 11/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

392 MONTAUK AVE APT 1
BROOKLYN NY
11208-3798
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3148
  • Fax:
Mailing address:
  • Phone: 646-255-3944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406175
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF346010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: