Healthcare Provider Details

I. General information

NPI: 1780304691
Provider Name (Legal Business Name): AVANNA PAIGE KOTLARZ FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FORT WASHINGTON AVE
NEW YORK NY
10032-3729
US

IV. Provider business mailing address

630 W 168TH ST # 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF350098-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF350098
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: