MEDICARE: MRS. PON IDA BENNY REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	406734	NY

General Provider Information

NPI Number	:	1609395524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PON IDA BENNY REGISTERED NURSE

Provider Business Mailing Address
First Line	:	67 MANHATTAN CT APT B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6205
Country	:	US
Telephone Number	:	718-616-3991
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 OCEAN PARKWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-1123
Country	:	US
Telephone Number	:	718-616-3991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	09/12/2017

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