Provider Demographics
NPI:1255689451
Name:DE LA CRUZ, JUDITH VIANEL
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:VIANEL
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 W 111TH ST
Mailing Address - Street 2:# 43
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1900
Mailing Address - Country:US
Mailing Address - Phone:917-238-8914
Mailing Address - Fax:
Practice Address - Street 1:503 W 111TH ST
Practice Address - Street 2:# 43
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1900
Practice Address - Country:US
Practice Address - Phone:917-238-8914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist