Provider Demographics
NPI:1396406179
Name:BEATRICE, FAIDA
Entity Type:Individual
Prefix:MISS
First Name:FAIDA
Middle Name:
Last Name:BEATRICE
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 1:144 JASPER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1557
Mailing Address - Country:US
Mailing Address - Phone:323-896-9401
Mailing Address - Fax:
Practice Address - Street 1:144 JASPER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1557
Practice Address - Country:US
Practice Address - Phone:323-896-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133036773172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver