Healthcare Provider Details

I. General information

NPI: 1538933379
Provider Name (Legal Business Name): ANGELA KAKURIYEVA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8002 KEW GARDENS RD STE 107
KEW GARDENS NY
11415-3600
US

IV. Provider business mailing address

15055 78TH RD
FLUSHING NY
11367-3539
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-0900
  • Fax:
Mailing address:
  • Phone: 917-887-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: