Healthcare Provider Details

I. General information

NPI: 1407316722
Provider Name (Legal Business Name): WANDA RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 SQUAREVIEW LN
ROCHESTER NY
14626-1868
US

IV. Provider business mailing address

196 SQUAREVIEW LN
ROCHESTER NY
14626-1868
US

V. Phone/Fax

Practice location:
  • Phone: 585-576-7764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number7386421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: