Healthcare Provider Details

I. General information

NPI: 1346663127
Provider Name (Legal Business Name): GLADYS KNOWLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 ROUTE 112
MEDFORD NY
11763-1446
US

IV. Provider business mailing address

3251 ROUTE 112
MEDFORD NY
11763-1446
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax: 631-297-8121
Mailing address:
  • Phone: 631-451-6007
  • Fax: 631-297-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6812
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: