Provider Demographics
NPI:1700281961
Name:NDUKAUBA, GERTRUDE SR
Entity Type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:
Last Name:NDUKAUBA
Suffix:SR
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 1:17117 110TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-3466
Mailing Address - Country:US
Mailing Address - Phone:347-475-2426
Mailing Address - Fax:
Practice Address - Street 1:22121 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2015
Practice Address - Country:US
Practice Address - Phone:718-468-6923
Practice Address - Fax:718-228-7597
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313575164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse