Provider Demographics
NPI:1396007761
Name:PHANORD, PAULETTE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:PHANORD
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1560
Mailing Address - Country:US
Mailing Address - Phone:718-671-2100
Mailing Address - Fax:
Practice Address - Street 1:2054 TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1560
Practice Address - Country:US
Practice Address - Phone:718-671-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298359164W00000X
NY731278-01163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse