Healthcare Provider Details

I. General information

NPI: 1740805563
Provider Name (Legal Business Name): JULISSA RODRIGUEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E 42ND ST FL 7
NEW YORK NY
10017-5806
US

IV. Provider business mailing address

6014 FRESH POND RD APT 2
MASPETH NY
11378-3454
US

V. Phone/Fax

Practice location:
  • Phone: 212-609-1920
  • Fax:
Mailing address:
  • Phone: 347-891-8173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309593
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: