Basic Information
| Provider Information | |||||||||
| NPI: | 1558341719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCKENTHAL | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168765555 | ||||||||
| FaxNumber: | 5168765539 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 TERRY RD | ||||||||
| Address2: | |||||||||
| City: | SMITHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117873894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317247246 | ||||||||
| FaxNumber: | 6317246377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 340956 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02443167 | 05 | NY | MEDICAID |