Basic Information
| Provider Information | |||||||||
| NPI: | 1306358205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | JULISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3018 KINGSBRIDGE AVE APT 2M | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104635107 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 263 BLUE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 329745 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 385949563 | 01 | NY | DRIVERS LICENSE | OTHER |