=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306218318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVERLYNE A NAMUNYU RN-FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2015
-----------------------------------------------------
Last Update Date | 10/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 774 MANOR RD SUITE 204
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-7038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-494-0033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 CHESTER PL APT 2C
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-331-5367
-----------------------------------------------------
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 | F339993-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------