Basic Information
Provider Information | |||||||||
NPI: | 1508999376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZENON | ||||||||
FirstName: | KRISTINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAKER | ||||||||
OtherFirstName: | KRISTINA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 56-45 MAIN STREET | ||||||||
Address2: | W-LL300 | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113555045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186701837 | ||||||||
FaxNumber: | 7186617186 | ||||||||
Practice Location | |||||||||
Address1: | 5620 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113555046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186701837 | ||||||||
FaxNumber: | 7186617186 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2007 | ||||||||
LastUpdateDate: | 12/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F3033381 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 02242428 | 05 | NY |   | MEDICAID |