Provider Demographics
NPI:1124194543
Name:REILLY, MIREYA (NP)
Entity Type:Individual
Prefix:MS
First Name:MIREYA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST # 4
Mailing Address - Street 2:VC 12TH FLOOR, SUITE 208
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02734958Medicaid
NY02734958Medicaid
NY1620G1Medicare ID - Type Unspecified