=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043402357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIYA WANICH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2007
-----------------------------------------------------
Last Update Date | 10/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 216 ENGLE ST SUITE 101
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-816-9800
-----------------------------------------------------
Fax | 201-567-1569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 ENGLE STREET SUITE 101
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-816-9800
-----------------------------------------------------
Fax | 201-567-1569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | 230693
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | 104650
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------