Healthcare Provider Details

I. General information

NPI: 1750165759
Provider Name (Legal Business Name): GRACE WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 KISSENA BLVD
FLUSHING NY
11355-3213
US

IV. Provider business mailing address

13815 68TH DR
FLUSHING NY
11367-1657
US

V. Phone/Fax

Practice location:
  • Phone: 718-888-7907
  • Fax:
Mailing address:
  • Phone: 646-733-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number351968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: