Provider Demographics
NPI:1477124667
Name:MENJIVAR, RAQUEL M
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:M
Last Name:MENJIVAR
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 1:2311 CORNAGA AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2509
Mailing Address - Country:US
Mailing Address - Phone:929-401-6428
Mailing Address - Fax:
Practice Address - Street 1:2311 CORNAGA AVE APT 6L
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2509
Practice Address - Country:US
Practice Address - Phone:929-401-6428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY817729163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse