Provider Demographics
NPI:1548414709
Name:JEANNINE, MAYA
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:JEANNINE
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 1:801 TILDEN ST
Mailing Address - Street 2:APT 24B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-6026
Mailing Address - Country:US
Mailing Address - Phone:646-385-5686
Mailing Address - Fax:
Practice Address - Street 1:801 TILDEN ST
Practice Address - Street 2:APT 24B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6026
Practice Address - Country:US
Practice Address - Phone:646-385-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277640164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse