Healthcare Provider Details

I. General information

NPI: 1588003776
Provider Name (Legal Business Name): ANDREA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8825 163RD ST
JAMAICA NY
11432-4046
US

IV. Provider business mailing address

241 E 55TH ST APT 2R
BROOKLYN NY
11203-4740
US

V. Phone/Fax

Practice location:
  • Phone: 718-739-0045
  • Fax:
Mailing address:
  • Phone: 718-462-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number305003
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: