Healthcare Provider Details

I. General information

NPI: 1336878891
Provider Name (Legal Business Name): ITEONA ROUNDTREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

72 WHITE RD
SHREWSBURY NJ
07702-4033
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-2323
  • Fax:
Mailing address:
  • Phone: 732-693-1885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number743130
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: