Healthcare Provider Details

I. General information

NPI: 1063136711
Provider Name (Legal Business Name): ALLEGRA DACOSTA-WALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E 74TH ST
NEW YORK NY
10021-3459
US

IV. Provider business mailing address

11314 72ND RD APT 2P
FOREST HILLS NY
11375-4610
US

V. Phone/Fax

Practice location:
  • Phone: 917-477-9594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number714420
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number714420
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: