Healthcare Provider Details

I. General information

NPI: 1881951747
Provider Name (Legal Business Name): EDWARD KWAKU OWUSU LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 E 3RD ST APT. B 21
MOUNT VERNON NY
10550-3953
US

IV. Provider business mailing address

23 E 3RD ST APT. B 21
MOUNT VERNON NY
10550-3953
US

V. Phone/Fax

Practice location:
  • Phone: 914-309-4250
  • Fax:
Mailing address:
  • Phone: 914-309-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number308986-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: