MEDICARE: MRS. PHYLLIS ALEXANDRIA BAIN N.P.

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	363L00000X	Nurse Practitioner	F420296	NY

General Provider Information

NPI Number	:	1902004559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PHYLLIS ALEXANDRIA BAIN N.P.

Provider Business Mailing Address
First Line	:	1719 NEWKIRK AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-6613
Country	:	US
Telephone Number	:	718-469-0416
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 CLARKSON AVE
Second Line	:	BUILDING E
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2057
Country	:	US
Telephone Number	:	718-245-3267
Fax Number	:

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

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	07/08/2007

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