=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558745018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRITTANY NICOLE GANNON PHD, MSN, AGPCNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 W 168TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-326-5705
-----------------------------------------------------
Fax | 212-342-0093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 W 168TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-326-5705
-----------------------------------------------------
Fax | 212-342-0093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9343603
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 309024
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------