Healthcare Provider Details

I. General information

NPI: 1639326697
Provider Name (Legal Business Name): GENINA TERESE LA LAND RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 GLENMERE LN
CORAM NY
11727-1428
US

IV. Provider business mailing address

55 GLENMERE LN
CORAM NY
11727-1428
US

V. Phone/Fax

Practice location:
  • Phone: 631-922-0929
  • Fax:
Mailing address:
  • Phone: 631-922-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number603547
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: