Healthcare Provider Details

I. General information

NPI: 1689054199
Provider Name (Legal Business Name): ELLEN KUDROW FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST M-404
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

1630 E 22ND ST
BROOKLYN NY
11210-5125
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5156
  • Fax: 212-746-8223
Mailing address:
  • Phone: 718-915-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403317
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF339008-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: