Healthcare Provider Details

I. General information

NPI: 1073083887
Provider Name (Legal Business Name): MINI DAVID RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

22 DURHAM RD
NEW HYDE PARK NY
11040-2051
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-4002
  • Fax:
Mailing address:
  • Phone: 347-255-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number663094-I
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: