Healthcare Provider Details

I. General information

NPI: 1245914209
Provider Name (Legal Business Name): SYBIL LING OLMO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6433 MADISON ST
RIDGEWOOD NY
11385-4629
US

IV. Provider business mailing address

6433 MADISON ST FL 1
RIDGEWOOD NY
11385-4629
US

V. Phone/Fax

Practice location:
  • Phone: 718-406-1393
  • Fax:
Mailing address:
  • Phone: 718-406-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number711875
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF345574-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: