Provider Demographics
NPI:1689471120
Name:FARFAN OTAVALO, KEYLA DE LOS ANGELES (RN)
Entity type:Individual
Prefix:
First Name:KEYLA
Middle Name:DE LOS ANGELES
Last Name:FARFAN OTAVALO
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 DOREEN DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2136
Mailing Address - Country:US
Mailing Address - Phone:917-573-9043
Mailing Address - Fax:
Practice Address - Street 1:2811 QUEENS PLZ N FL 5
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4172
Practice Address - Country:US
Practice Address - Phone:718-391-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY914526163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse