Healthcare Provider Details

I. General information

NPI: 1093094435
Provider Name (Legal Business Name): MRS. HEATHER ANNE KANGUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17810 WEXFORD TER
JAMAICA NY
11432-3050
US

IV. Provider business mailing address

17810 WEXFORD TERRACE #1F
JAMAICA NY
11432
US

V. Phone/Fax

Practice location:
  • Phone: 718-658-1123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number076928-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: