Healthcare Provider Details

I. General information

NPI: 1396496436
Provider Name (Legal Business Name): MR. BRYAN HOWARD QUACKENBUSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 08/21/2022
Certification Date: 08/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 BERME RD
NAPANOCH NY
12458-2709
US

IV. Provider business mailing address

105 BELVEDERE RD
BEACON NY
12508-2421
US

V. Phone/Fax

Practice location:
  • Phone: 845-647-1670
  • Fax:
Mailing address:
  • Phone: 845-264-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN676013
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number702414
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404392
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: