Provider Demographics
NPI:1780404681
Name:INNOCENT, SONIA
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:INNOCENT
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 1:147 ELM ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4913
Mailing Address - Country:US
Mailing Address - Phone:347-856-4652
Mailing Address - Fax:
Practice Address - Street 1:147 ELM ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4913
Practice Address - Country:US
Practice Address - Phone:347-856-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406362-01163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty