Provider Demographics
NPI:1104178151
Name:CRUZ, BECKY A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:A
Last Name:CRUZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:BECKY
Other - Middle Name:A
Other - Last Name:CRUZ-ENWEREUZOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:3711 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1725
Mailing Address - Country:US
Mailing Address - Phone:718-361-5100
Mailing Address - Fax:
Practice Address - Street 1:3711 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-1725
Practice Address - Country:US
Practice Address - Phone:718-361-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311997164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse