Healthcare Provider Details

I. General information

NPI: 1982934857
Provider Name (Legal Business Name): AUDREY GROVENOR L P N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 225TH ST QUEENS VILLAGE
QUEENS VILLAGE NY
11429-2825
US

IV. Provider business mailing address

11010 225TH ST QUEENS VILLAGE
QUEENS VILLAGE NY
11429-2825
US

V. Phone/Fax

Practice location:
  • Phone: 718-776-4683
  • Fax:
Mailing address:
  • Phone: 718-776-4683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number107886-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: