Provider Demographics
NPI:1659030096
Name:JAGNARINE-DHAUTAL, RADHA
Entity Type:Individual
Prefix:
First Name:RADHA
Middle Name:
Last Name:JAGNARINE-DHAUTAL
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 1:13338 117TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3127
Mailing Address - Country:US
Mailing Address - Phone:917-294-5449
Mailing Address - Fax:
Practice Address - Street 1:9407 156TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2826
Practice Address - Country:US
Practice Address - Phone:718-323-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily