Provider Demographics
NPI:1154044790
Name:CEVALLOS, ROMINA A (RN)
Entity type:Individual
Prefix:
First Name:ROMINA
Middle Name:A
Last Name:CEVALLOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WILLOWBROOK AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8532
Mailing Address - Country:US
Mailing Address - Phone:934-500-9162
Mailing Address - Fax:
Practice Address - Street 1:5 WILLOWBROOK AVE APT 5A
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8532
Practice Address - Country:US
Practice Address - Phone:934-500-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY85237301163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice