Healthcare Provider Details

I. General information

NPI: 1528313640
Provider Name (Legal Business Name): JAMIE LYN BRENNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2012
Last Update Date: 07/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 NESCONSET HWY
PORT JEFF STA NY
11776-2053
US

IV. Provider business mailing address

PO BOX 709
ROCKY POINT NY
11778-0709
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-2204
  • Fax:
Mailing address:
  • Phone: 516-810-5273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number450274101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: