Healthcare Provider Details

I. General information

NPI: 1386379436
Provider Name (Legal Business Name): ALYSA ANDRADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

157 WILD AVE
STATEN ISLAND NY
10314-4727
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9000
  • Fax:
Mailing address:
  • Phone: 718-309-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number432493
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number707617
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: