Healthcare Provider Details

I. General information

NPI: 1205502390
Provider Name (Legal Business Name): ANELIA LARA PERSAD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY # E2-69
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY # E2-69
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-2880
  • Fax: 718-334-5006
Mailing address:
  • Phone: 718-334-2880
  • Fax: 718-334-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number718930
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1068127
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: