Provider Demographics
NPI:1578127817
Name:SIMAREN, BUKONOLA SIDIKAT (RN)
Entity Type:Individual
Prefix:MRS
First Name:BUKONOLA
Middle Name:SIDIKAT
Last Name:SIMAREN
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 1:14E ROXY PL
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2951
Mailing Address - Country:US
Mailing Address - Phone:516-551-8983
Mailing Address - Fax:516-551-8983
Practice Address - Street 1:14E ROXY PL
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2951
Practice Address - Country:US
Practice Address - Phone:516-551-8983
Practice Address - Fax:516-551-8983
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY747888163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty