MEDICARE: MRS. VALLERY PHILLESETER DACOSTA RN

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	423102-1	NY

General Provider Information

NPI Number	:	1700184785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VALLERY PHILLESETER DACOSTA RN

Provider Business Mailing Address
First Line	:	3244 WILSON AVE
Second Line	:	PH
City	:	BRONX
State	:	NY
Zip	:	10469-2908
Country	:	US
Telephone Number	:	718-655-8326
Fax Number	:

Provider Business Practice Location Address
First Line	:	3244 WILSON AVE
Second Line	:	PH
City	:	BRONX
State	:	NY
Zip	:	10469-2908
Country	:	US
Telephone Number	:	718-655-8326
Fax Number	:

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

Provider Enumeration Date	:	03/01/2011
Last Update Date	:	03/01/2011

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