=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083435119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL STONE FAMILY HEALTH NP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1017 BURKE AVE PH
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10469-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-543-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1017 BURKE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10469-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-543-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MR. CHARLES K OFORI-AMPOMAH
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 347-543-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------