Provider Demographics
NPI:1508470741
Name:SAN PEDRO, ANABELLE MALONG
Entity Type:Individual
Prefix:
First Name:ANABELLE
Middle Name:MALONG
Last Name:SAN PEDRO
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 1:4195 FORLEY ST FL 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2656
Mailing Address - Country:US
Mailing Address - Phone:347-264-3079
Mailing Address - Fax:
Practice Address - Street 1:4195 FORLEY ST FL 3
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2656
Practice Address - Country:US
Practice Address - Phone:347-264-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY685112163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY908100967OtherNEW YORK STATE IDENTIFICATION CARD