=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992060875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISABEL TEJADA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2012
-----------------------------------------------------
Last Update Date | 07/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3711 QUEENS BLVD
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11101-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-361-5100
-----------------------------------------------------
Fax | 718-361-5185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5718 65TH ST
-----------------------------------------------------
City | MASPETH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11378-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-813-1142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 305828
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------