Provider Demographics
NPI:1568772952
Name:NURSE PRACTITIONER WOMEN'S HEALTH, PLLC
Entity Type:Organization
Organization Name:NURSE PRACTITIONER WOMEN'S HEALTH, PLLC
Other - Org Name:LIFESTYLE WELLNESS ENTERPRISE, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOHNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:1718-379-1290
Mailing Address - Street 1:140 DARROW PL
Mailing Address - Street 2:SUITE 16B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1802
Mailing Address - Country:US
Mailing Address - Phone:718-379-1290
Mailing Address - Fax:718-379-8597
Practice Address - Street 1:140 DARROW PL
Practice Address - Street 2:SUITE 16B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1802
Practice Address - Country:US
Practice Address - Phone:718-379-1290
Practice Address - Fax:718-379-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420329-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS87741Medicare UPIN