Healthcare Provider Details

I. General information

NPI: 1841123957
Provider Name (Legal Business Name): JARED BOATENG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NORRIS ST
GARNERVILLE NY
10923-1205
US

IV. Provider business mailing address

29 NORRIS ST
GARNERVILLE NY
10923-1205
US

V. Phone/Fax

Practice location:
  • Phone: 951-907-8936
  • Fax:
Mailing address:
  • Phone: 951-907-8936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN32925
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: