Healthcare Provider Details

I. General information

NPI: 1518723550
Provider Name (Legal Business Name): IVY CUDJOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 QUEENS PLZ N
LONG ISLAND CITY NY
11101-4172
US

IV. Provider business mailing address

2075 GRAND CONCOURSE APT 5A
BRONX NY
10453-3821
US

V. Phone/Fax

Practice location:
  • Phone: 718-391-8300
  • Fax:
Mailing address:
  • Phone: 918-999-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number88031001
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: