Basic Information
| Provider Information | |||||||||
| NPI: | 1720659634 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NURSE PRACTITIONER IN ADULT GERONTOLOGY FAMILY AND PALLATIVE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 169 S MAIN STREET | ||||||||
| Address2: | SUITE 352 | ||||||||
| City: | NEW CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444828677 | ||||||||
| FaxNumber: | 7187631203 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 S MAIN STREET | ||||||||
| Address2: | SUITE 352 | ||||||||
| City: | NEW CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444828677 | ||||||||
| FaxNumber: | 7187631203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2021 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPHINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9179152866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | N.P. | ||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | Y | Agencies | Nursing Care |
No ID Information.