=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407040280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCCUPATIONAL HEALTH SERVICES RPN NP ADULT HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2007
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187-189 CENTER STREET
-----------------------------------------------------
City | SALAMANCA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14779-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-945-2825
-----------------------------------------------------
Fax | 716-945-2827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 375 187-189 CENTER STREET
-----------------------------------------------------
City | SALAMANCA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14779-0375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-945-2825
-----------------------------------------------------
Fax | 716-945-2827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. GWEN ELIZABETH BRUNO
-----------------------------------------------------
Credential | ANP
-----------------------------------------------------
Telephone | 716-945-2825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F303946 1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------