Provider Demographics
NPI:1386294247
Name:BUENO, WANDA J (LPN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:BUENO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:J
Other - Last Name:BUENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:530 E 169TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-2616
Mailing Address - Country:US
Mailing Address - Phone:646-919-4296
Mailing Address - Fax:
Practice Address - Street 1:530 E 169TH ST APT 7D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-2667
Practice Address - Country:US
Practice Address - Phone:646-919-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3319513-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112215Medicaid