Healthcare Provider Details

I. General information

NPI: 1821148222
Provider Name (Legal Business Name): CAROLINE AMENAGHAWON UGBOGBO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19616 HILLSIDE AVE
HOLLIS NY
11423-2125
US

IV. Provider business mailing address

464 HOPATCONG AVE
WEST HEMPSTEAD NY
11552-4302
US

V. Phone/Fax

Practice location:
  • Phone: 718-217-6806
  • Fax:
Mailing address:
  • Phone: 516-764-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3043O7
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: