=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336878891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ITEONA ROUNDTREE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1275 YORK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-639-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72 WHITE RD
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-693-1885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 743130
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------