Healthcare Provider Details

I. General information

NPI: 1588392617
Provider Name (Legal Business Name): BIANCA LYDER CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E 138TH ST APT 12D
NEW YORK NY
10037-2037
US

IV. Provider business mailing address

10 E 138TH ST APT 12D
NEW YORK NY
10037-2037
US

V. Phone/Fax

Practice location:
  • Phone: 917-209-5099
  • Fax:
Mailing address:
  • Phone: 917-209-5099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number22LY0113056
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: