Healthcare Provider Details

I. General information

NPI: 1245753680
Provider Name (Legal Business Name): CHINYERE ESEDEBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14203 174TH ST
JAMAICA NY
11434-4629
US

IV. Provider business mailing address

14203 174TH ST
JAMAICA NY
11434-4629
US

V. Phone/Fax

Practice location:
  • Phone: 516-495-0775
  • Fax:
Mailing address:
  • Phone: 516-495-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number327848
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: