Healthcare Provider Details

I. General information

NPI: 1205185444
Provider Name (Legal Business Name): RAVELLA JAINARAIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 211TH PL
QUEENS VILLAGE NY
11429-1545
US

IV. Provider business mailing address

10415 211TH PL
QUEENS VILLAGE NY
11429-1545
US

V. Phone/Fax

Practice location:
  • Phone: 917-224-0216
  • Fax:
Mailing address:
  • Phone: 917-224-0216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF305457-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: