MEDICARE: MRS. LYANNE STEPHANIE WONSANG-BASURTO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	773539	NY
2	163W00000X	Registered Nurse	041.576850	IL

General Provider Information

NPI Number	:	1164303830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYANNE STEPHANIE WONSANG-BASURTO

Provider Business Mailing Address
First Line	:	2247 128TH ST FL 2
Second Line	:
City	:	COLLEGE POINT
State	:	NY
Zip	:	11356-2721
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2247 128TH ST FL 2
Second Line	:
City	:	COLLEGE POINT
State	:	NY
Zip	:	11356-2721
Country	:	US
Telephone Number	:	347-617-5695
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2025
Last Update Date	:	06/07/2026

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