Provider Demographics
NPI:1629195904
Name:BEDWARD, IMOGENE P (NP)
Entity Type:Individual
Prefix:MS
First Name:IMOGENE
Middle Name:P
Last Name:BEDWARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 NAMEOKE ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4906
Mailing Address - Country:US
Mailing Address - Phone:718-327-3723
Mailing Address - Fax:
Practice Address - Street 1:1045 NAMEOKE ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4906
Practice Address - Country:US
Practice Address - Phone:718-327-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354865163W00000X
NYF381145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner