Provider Demographics
NPI:1275110405
Name:TERLONGE, BIANCA SALLY
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:SALLY
Last Name:TERLONGE
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 1:11419 205TH ST PH
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2909
Mailing Address - Country:US
Mailing Address - Phone:929-494-5783
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2472R0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis