Healthcare Provider Details

I. General information

NPI: 1891366332
Provider Name (Legal Business Name): JACQUELINE KRISTEN MOUNAYAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 646-962-2150
  • Fax: 212-746-6951
Mailing address:
  • Phone: 646-962-2150
  • Fax: 212-746-6951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9790
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number310275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: