Provider Demographics
NPI:1588295034
Name:TAYESE, VICTORIA (FNP)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:
Last Name:TAYESE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14791 BROOKVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3240
Mailing Address - Country:US
Mailing Address - Phone:646-691-2958
Mailing Address - Fax:
Practice Address - Street 1:501 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5807
Practice Address - Country:US
Practice Address - Phone:516-361-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY461629-1163WP0809X
NYF348784-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult