Healthcare Provider Details

I. General information

NPI: 1306951314
Provider Name (Legal Business Name): LI-CHEN L WANN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LAKEVILLE RD, SUITE 107
NEW HYDE PARK NY
11040
US

IV. Provider business mailing address

410 LAKEVILLE RD, SUITE 107
NEW HYDE PARK NY
11040
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-5419
  • Fax: 516-465-5454
Mailing address:
  • Phone: 516-465-5419
  • Fax: 516-465-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberF301307 / 412733
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: