=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417622002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. ROSE NELLIE BAYRON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | JOHN F. KENNEDY INTERNATIONAL AIRPORT TERMINAL 4
-----------------------------------------------------
City | QUEENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11430-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-751-4319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1675 METROPOLITAN AVE APT 4B
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-6288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-259-9678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 025635
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------