Provider Demographics
NPI:1407455884
Name:SOUVENANCE, VEDALIE (NP)
Entity type:Individual
Prefix:
First Name:VEDALIE
Middle Name:
Last Name:SOUVENANCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VEDALIE
Other - Middle Name:
Other - Last Name:SOUVENANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1266 DEKOVEN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3402
Mailing Address - Country:US
Mailing Address - Phone:917-825-0930
Mailing Address - Fax:
Practice Address - Street 1:21229 HILLSIDE AVE APT 3JE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1851
Practice Address - Country:US
Practice Address - Phone:917-825-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311426-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY784731-01OtherNURSING LICENSE
NYF311426-01OtherNP LICENSE
NYF311426-01Medicaid