Healthcare Provider Details

I. General information

NPI: 1679397657
Provider Name (Legal Business Name): MICAH REHANA BARDELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 PONDFIELD RD
BRONXVILLE NY
10708-3809
US

IV. Provider business mailing address

47 BLUFF AVE
GREENWOOD LAKE NY
10925-4408
US

V. Phone/Fax

Practice location:
  • Phone: 914-337-4986
  • Fax:
Mailing address:
  • Phone: 845-492-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355452
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: