Provider Demographics
NPI:1750617320
Name:FORMOSO, NORMA ELIZABETH
Entity type:Individual
Prefix:
First Name:NORMA
Middle Name:ELIZABETH
Last Name:FORMOSO
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 1:22413 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1462
Mailing Address - Country:US
Mailing Address - Phone:718-413-4485
Mailing Address - Fax:
Practice Address - Street 1:22413 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1462
Practice Address - Country:US
Practice Address - Phone:718-413-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217854164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse