Provider Demographics
NPI:1114301728
Name:HAIDOME, EREWARIFAGHA MININI (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:EREWARIFAGHA
Middle Name:MININI
Last Name:HAIDOME
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MISS
Other - First Name:EREWARI
Other - Middle Name:MININI
Other - Last Name:PETERSIDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:3963 MURDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2442
Mailing Address - Country:US
Mailing Address - Phone:347-281-0304
Mailing Address - Fax:
Practice Address - Street 1:14036 170TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4632
Practice Address - Country:US
Practice Address - Phone:347-843-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621055-1163W00000X
NY403564363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1114301728OtherNPI