Provider Demographics
NPI:1265003172
Name:MINOTT, VARDRINE JANELLE
Entity Type:Individual
Prefix:
First Name:VARDRINE
Middle Name:JANELLE
Last Name:MINOTT
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 1:1809 ALBEMARLE RD APT A11
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-8010
Mailing Address - Country:US
Mailing Address - Phone:718-710-3786
Mailing Address - Fax:
Practice Address - Street 1:21111 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3241
Practice Address - Country:US
Practice Address - Phone:212-273-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323746164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty