Healthcare Provider Details

I. General information

NPI: 1689189581
Provider Name (Legal Business Name): LYUDMILA BRODETSKAYA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GATEWAY CTR STE 2600
NEWARK NJ
07102-5323
US

IV. Provider business mailing address

1 GATEWAY CTR STE 2600
NEWARK NJ
07102-5323
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 888-731-8994
  • Fax: 833-775-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ14901200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF339392-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: