Provider Demographics
NPI:1659721892
Name:OKUESI, KISHA
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:OKUESI
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 1:2217 TROY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3618
Mailing Address - Country:US
Mailing Address - Phone:646-236-0575
Mailing Address - Fax:
Practice Address - Street 1:1111 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-3785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-19
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634678-1163WM0705X
NYF3415331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Multi-Specialty