=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720659634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NURSE PRACTITIONER IN ADULT GERONTOLOGY FAMILY AND PALLATIVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2021
-----------------------------------------------------
Last Update Date | 07/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 169 S MAIN STREET SUITE 352
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-482-8677
-----------------------------------------------------
Fax | 718-763-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 169 S MAIN STREET SUITE 352
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-482-8677
-----------------------------------------------------
Fax | 718-763-1203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | JOSEPHINE GABRIEL
-----------------------------------------------------
Credential | N.P.
-----------------------------------------------------
Telephone | 917-915-2866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------