Healthcare Provider Details

I. General information

NPI: 1417544990
Provider Name (Legal Business Name): NANAN CISSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 5TH AVE
NEW YORK NY
10035-4521
US

IV. Provider business mailing address

2156 HONE AVE
BRONX NY
10461-1250
US

V. Phone/Fax

Practice location:
  • Phone: 646-289-7731
  • Fax: 646-289-7791
Mailing address:
  • Phone: 212-690-0528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number742537-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: