Healthcare Provider Details

I. General information

NPI: 1831883404
Provider Name (Legal Business Name): BREANNA NICOLE VANDYK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date: 12/13/2024
Reactivation Date: 01/28/2025

III. Provider practice location address

140 HAMMOND ST
PORT JERVIS NY
12771-2607
US

IV. Provider business mailing address

2570 ROUTE 9W STE 10
CORNWALL NY
12518-1370
US

V. Phone/Fax

Practice location:
  • Phone: 845-563-8000
  • Fax:
Mailing address:
  • Phone: 845-220-3100
  • Fax: 845-534-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355846
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: