=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245670181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENIECE TRAST RN, MA, CDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2013
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3415 BAINBRIDGE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-920-6191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3415 BAINBRIDGE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-920-6191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WD0400X
-----------------------------------------------------
Taxonomy Name | Diabetes Educator Registered Nurse
-----------------------------------------------------
License Number | 22-578778
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------