Healthcare Provider Details

I. General information

NPI: 1467678763
Provider Name (Legal Business Name): ILENE TANNENBAUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BEDFORD AVE 114 ROOSEVELT
BROOKLYN NY
11210-2850
US

IV. Provider business mailing address

723 E 18TH ST
BROOKLYN NY
11230-1802
US

V. Phone/Fax

Practice location:
  • Phone: 718-951-5580
  • Fax: 718-951-5869
Mailing address:
  • Phone: 718-859-9269
  • Fax: 718-951-5869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420087
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: