Provider Demographics
NPI:1699220566
Name:WISBORO, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WISBORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:YVETTE
Other - Last Name:ACEVEDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21 REGAL WALK
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2904
Mailing Address - Country:US
Mailing Address - Phone:646-229-4946
Mailing Address - Fax:
Practice Address - Street 1:21 REGAL WALK
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2904
Practice Address - Country:US
Practice Address - Phone:646-229-4946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist