Healthcare Provider Details

I. General information

NPI: 1619285814
Provider Name (Legal Business Name): GERTHA BOUCICAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21211 102ND AVE APT. C4
QUEENS VILLAGE NY
11429-1106
US

IV. Provider business mailing address

21211 102ND AVE APT. C4
QUEENS VILLAGE NY
11429-1106
US

V. Phone/Fax

Practice location:
  • Phone: 718-468-8298
  • Fax:
Mailing address:
  • Phone: 718-468-8298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF345182-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number573530
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: