Healthcare Provider Details

I. General information

NPI: 1629963103
Provider Name (Legal Business Name): WENDY ILENE WEISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WATER ST STE 401
WHITE PLAINS NY
10601-1401
US

IV. Provider business mailing address

188 LAGOON DR W
LIDO BEACH NY
11561-4916
US

V. Phone/Fax

Practice location:
  • Phone: 914-949-3112
  • Fax:
Mailing address:
  • Phone: 516-776-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number825168
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: