Provider Demographics
NPI:1902117567
Name:VILLANUEVA, WENDELL
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 5TH AVE RM 1413
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6628
Mailing Address - Country:US
Mailing Address - Phone:212-481-8678
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 1413
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6628
Practice Address - Country:US
Practice Address - Phone:212-481-8678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY612828163W00000X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163W00000XNursing Service ProvidersRegistered Nurse