Healthcare Provider Details

I. General information

NPI: 1194109165
Provider Name (Legal Business Name): TRACY HOONG YEE TAN-LIBREROS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2015
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9610 METROPOLITAN AVE
FOREST HILLS NY
11375-6625
US

IV. Provider business mailing address

55 WATER STREET 2ND FLOOR CRED DEPT
NEW YORK NY
10041-0010
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-0400
  • Fax: 718-670-6479
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307224
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number599788
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: