Healthcare Provider Details

I. General information

NPI: 1750901229
Provider Name (Legal Business Name): GRACE BERNAUDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MINEOLA BLVD
MINEOLA NY
11501-4089
US

IV. Provider business mailing address

151 INGRAHAM LN
NEW HYDE PARK NY
11040-4275
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-3511
  • Fax: 516-663-2308
Mailing address:
  • Phone: 516-437-0796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number516568
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: