Provider Demographics
NPI:1972751691
Name:CROSS, THEODORA MONTELL (RN,MS,CNS,ANP-BC,CDE)
Entity type:Individual
Prefix:MS
First Name:THEODORA
Middle Name:MONTELL
Last Name:CROSS
Suffix:
Gender:F
Credentials:RN,MS,CNS,ANP-BC,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 COTTAGE PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1522
Mailing Address - Country:US
Mailing Address - Phone:718-816-8423
Mailing Address - Fax:718-816-5024
Practice Address - Street 1:79 COTTAGE PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1522
Practice Address - Country:US
Practice Address - Phone:718-816-8423
Practice Address - Fax:718-816-5024
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304508363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health