Healthcare Provider Details

I. General information

NPI: 1386983716
Provider Name (Legal Business Name): RACHAEL OBISANYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 BIRCH RD
STATEN ISLAND NY
10303-1718
US

IV. Provider business mailing address

69 BIRCH RD
STATEN ISLAND NY
10303-1718
US

V. Phone/Fax

Practice location:
  • Phone: 718-600-4554
  • Fax:
Mailing address:
  • Phone: 718-600-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number292895
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: