Provider Demographics
NPI:1114635760
Name:TAVAREZ, BRANNY FAUSTO (RN)
Entity Type:Individual
Prefix:
First Name:BRANNY
Middle Name:FAUSTO
Last Name:TAVAREZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 SEDGWICK AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3124
Mailing Address - Country:US
Mailing Address - Phone:646-698-1876
Mailing Address - Fax:
Practice Address - Street 1:790 BROADWAY # 11206
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5316
Practice Address - Country:US
Practice Address - Phone:718-388-5176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY855571-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse