Healthcare Provider Details

I. General information

NPI: 1124194543
Provider Name (Legal Business Name): MIREYA REILLY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

630 W 168TH ST # 4 VC 12TH FLOOR, SUITE 208
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF334329
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: