Provider Demographics
NPI:1861749517
Name:KIRKLAND, IDONNA (MSED)
Entity type:Individual
Prefix:MS
First Name:IDONNA
Middle Name:
Last Name:KIRKLAND
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MRS
Other - First Name:IDONNA
Other - Middle Name:
Other - Last Name:MANGUAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:120 DEBS PL APT 19A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-2532
Mailing Address - Country:US
Mailing Address - Phone:917-405-1589
Mailing Address - Fax:
Practice Address - Street 1:100 DE KRUIF PL
Practice Address - Street 2:APT 18C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-2402
Practice Address - Country:US
Practice Address - Phone:917-405-1589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY536702111174400000X
NY1367699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist