Provider Demographics
NPI:1376124297
Name:NURSE PRACTITIONER IN ADULT GERONTOLOGY FAMILY AND PALLATIVE
Entity Type:Organization
Organization Name:NURSE PRACTITIONER IN ADULT GERONTOLOGY FAMILY AND PALLATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:ZETILIA
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:917-915-2866
Mailing Address - Street 1:169 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3353
Mailing Address - Country:US
Mailing Address - Phone:917-915-2866
Mailing Address - Fax:
Practice Address - Street 1:100 WEST KINDSBRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-0355
Practice Address - Country:US
Practice Address - Phone:917-915-2866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1356367569Medicaid