Provider Demographics
NPI:1083278774
Name:LI, JIAYU (RN)
Entity Type:Individual
Prefix:MS
First Name:JIAYU
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15043 18TH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3124
Mailing Address - Country:US
Mailing Address - Phone:646-732-3174
Mailing Address - Fax:
Practice Address - Street 1:15043 18TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11357-3124
Practice Address - Country:US
Practice Address - Phone:646-732-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-28
Last Update Date:2019-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7625252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY689387478OtherDMV