Healthcare Provider Details

I. General information

NPI: 1750266805
Provider Name (Legal Business Name): MIKKO DANE VIUDEZ PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W 43RD ST APT 3K
NEW YORK NY
10036-0091
US

IV. Provider business mailing address

505 W 43RD ST APT 3K
NEW YORK NY
10036-0091
US

V. Phone/Fax

Practice location:
  • Phone: 630-456-5251
  • Fax:
Mailing address:
  • Phone: 630-456-5251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407437
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: