=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285323675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH CHRISTIE NURSE PRACTITIONER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2023
-----------------------------------------------------
Last Update Date | 05/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 TODT HILL RD STE 205
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-691-5537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 RAILY CT
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-1676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-366-0960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F349282-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------