Healthcare Provider Details

I. General information

NPI: 1457738486
Provider Name (Legal Business Name): BRITTANY VAN STAALDUINEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE
STATEN ISLAND NY
10310-1664
US

IV. Provider business mailing address

723 BROADWAY
STATEN ISLAND NY
10310-2833
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-1234
  • Fax:
Mailing address:
  • Phone: 718-494-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number298508
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: