Healthcare Provider Details

I. General information

NPI: 1538835194
Provider Name (Legal Business Name): NILAKSHALA MADUWANTHIE KONARA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 TOMPKINS AVE
STATEN ISLAND NY
10304-2601
US

IV. Provider business mailing address

91 TOMPKINS AVE
STATEN ISLAND NY
10304-2601
US

V. Phone/Fax

Practice location:
  • Phone: 718-876-1200
  • Fax:
Mailing address:
  • Phone: 718-876-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number723114
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number723114
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: