Provider Demographics
NPI:1407456940
Name:NUNEZ, IMANI ALEXIA
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:ALEXIA
Last Name:NUNEZ
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 1:3600 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4116
Mailing Address - Country:US
Mailing Address - Phone:631-920-8500
Mailing Address - Fax:631-920-8501
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-920-8500
Practice Address - Fax:631-920-8501
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program