Healthcare Provider Details

I. General information

NPI: 1558814517
Provider Name (Legal Business Name): CECILIA AJANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1701
US

IV. Provider business mailing address

439 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1714
US

V. Phone/Fax

Practice location:
  • Phone: 718-876-1732
  • Fax: 718-442-0189
Mailing address:
  • Phone: 718-876-1732
  • Fax: 718-442-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF339337-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: