Provider Demographics
NPI:1114344694
Name:BRISTOW, LENATA
Entity Type:Individual
Prefix:
First Name:LENATA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 RALPH AVE
Mailing Address - Street 2:UNIT 112
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5406
Mailing Address - Country:US
Mailing Address - Phone:347-489-1530
Mailing Address - Fax:
Practice Address - Street 1:264 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4431
Practice Address - Country:US
Practice Address - Phone:718-868-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator