Provider Demographics
NPI:1689823999
Name:SOUVERAIN, VARDA
Entity Type:Individual
Prefix:
First Name:VARDA
Middle Name:
Last Name:SOUVERAIN
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 1:2186 DUTCH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-3506
Mailing Address - Country:US
Mailing Address - Phone:917-627-0037
Mailing Address - Fax:
Practice Address - Street 1:2186 DUTCH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-3506
Practice Address - Country:US
Practice Address - Phone:917-627-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276819164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse