=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265026892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UGO UDEOCHU NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2021
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 W HAWTHORNE AVE FL 2
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-569-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15038 115TH DR
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11434-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-496-0634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 403420
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------