Basic Information
| Provider Information | |||||||||
| NPI: | 1285853549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTOPHE | ||||||||
| FirstName: | GLADYS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDPOUARD | ||||||||
| OtherFirstName: | GLADYS | ||||||||
| OtherMiddleName: | NOELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM.NP.MSN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 47 PINEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115762419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168014035 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CROWN HEIGHTS HEALTH CENTER | ||||||||
| Address2: | 1167 NOSTRAND AVENUE | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187780198 | ||||||||
| FaxNumber: | 7182218169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | F000131 | NY | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 02230537 | 05 | NY | MEDICAID |