Healthcare Provider Details

I. General information

NPI: 1619633559
Provider Name (Legal Business Name): KEYONA DARJE' JETER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 W 57TH ST
NEW YORK NY
10019-2121
US

IV. Provider business mailing address

241 W 57TH ST
NEW YORK NY
10019-2121
US

V. Phone/Fax

Practice location:
  • Phone: 212-547-5848
  • Fax:
Mailing address:
  • Phone: 212-247-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF348604
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: