Provider Demographics
NPI:1255585295
Name:BOATENG-WILSON, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BOATENG-WILSON
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 1:3198 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1000
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-429-8467
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:US
Practice Address - Phone:718-299-7294
Practice Address - Fax:718-294-6797
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY592824163W00000X
NY338663363LF0000X
NYF404138363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily