Healthcare Provider Details

I. General information

NPI: 1811260110
Provider Name (Legal Business Name): EMANCIA MYRIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 BLAKE AVENUE
BROOKLYN USA
11208
UM

IV. Provider business mailing address

60 MADISON AVE
NEW YORK NY
10010-1600
US

V. Phone/Fax

Practice location:
  • Phone: 718-277-8303
  • Fax: 718-277-4795
Mailing address:
  • Phone: 212-545-2400
  • Fax: 646-312-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF401426-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number478347-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number478347-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401426
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: