Provider Demographics
NPI:1508162397
Name:CUSTODIO, THERESA REYES (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:REYES
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PIER POINTE ST
Mailing Address - Street 2:APT 517
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-3569
Mailing Address - Country:US
Mailing Address - Phone:774-888-7724
Mailing Address - Fax:
Practice Address - Street 1:1 PIER POINTE ST
Practice Address - Street 2:APT 517
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-6941
Practice Address - Country:US
Practice Address - Phone:774-888-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608387-1163WH0200X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WH0200XNursing Service ProvidersRegistered NurseHome Health