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Provider Information for 1104247600

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: FEMALE

Individual NPI: 1104247600

Calendar   Last Updated:  2014-02-13
  Certification Date: 


Name Value
NPI 1104247600
Enumeration Date 2013-12-31
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 1767 BEDFORD AVE APT 5
BROOKLYN, NY 11225-3331
United States

Phone: 646-204-1116 | Fax:
View Map External Link
Primary Practice Address 2625 E 14TH ST STE 200
BROOKLYN, NY 11235-3973
United States

Phone: 718-769-2698 | Fax: 718-401-0108
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 174400000X - Specialist NY 688858