Basic Information
| Provider Information | |||||||||
| NPI: | 1225139041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULOUDJ | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | CARMEN AVE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165723945 | ||||||||
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| Practice Location | |||||||||
| Address1: | CARMEN AVE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165723945 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 432330 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 432330 | 01 | NY | LICENSE# | OTHER |