Healthcare Provider Details

I. General information

NPI: 1871355719
Provider Name (Legal Business Name): GRACE N. OTUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 HEMPSTEAD AVE
WEST HEMPSTEAD NY
11552-2042
US

IV. Provider business mailing address

319 HEMPSTEAD AVE
WEST HEMPSTEAD NY
11552-2042
US

V. Phone/Fax

Practice location:
  • Phone: 516-743-9233
  • Fax:
Mailing address:
  • Phone: 516-742-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311539
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: