Provider Demographics
NPI:1386020014
Name:DE LA CONCHA, AMELIA
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:DE LA CONCHA
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 1:1657 PAULDING AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3106
Mailing Address - Country:US
Mailing Address - Phone:347-920-8503
Mailing Address - Fax:
Practice Address - Street 1:3400 BAINBRIDGE AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2404
Practice Address - Country:US
Practice Address - Phone:718-920-2626
Practice Address - Fax:718-652-1833
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily