Healthcare Provider Details

I. General information

NPI: 1417358375
Provider Name (Legal Business Name): EILEEN MOYNIHAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

3618 CORLEAR AVE
BRONX NY
10463-2306
US

V. Phone/Fax

Practice location:
  • Phone: 646-996-5946
  • Fax:
Mailing address:
  • Phone: 646-996-5946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95011169
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6128
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: