Healthcare Provider Details

I. General information

NPI: 1306170402
Provider Name (Legal Business Name): BRENDA MINTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENDA KOSCHITZKI

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 RIVERDALE AVE
BRONX NY
10463-1815
US

IV. Provider business mailing address

1021 WESTWOOD RD
WOODMERE NY
11598-1124
US

V. Phone/Fax

Practice location:
  • Phone: 718-362-1411
  • Fax: 718-414-1651
Mailing address:
  • Phone: 917-204-5445
  • Fax: 516-765-2682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number543750
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341692
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: