Healthcare Provider Details

I. General information

NPI: 1194228080
Provider Name (Legal Business Name): ANNASTECIA MBAGWU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SUMMIT AVE FL 3
WHITE PLAINS NY
10606-3003
US

IV. Provider business mailing address

1 SUMMIT AVE FL 3
WHITE PLAINS NY
10606-3003
US

V. Phone/Fax

Practice location:
  • Phone: 347-499-2400
  • Fax:
Mailing address:
  • Phone: 347-499-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF359223
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number330409-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: