Provider Demographics
NPI:1467678763
Name:TANNENBAUM, ILENE (NP)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:TANNENBAUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1802
Mailing Address - Country:US
Mailing Address - Phone:718-859-9269
Mailing Address - Fax:718-951-5869
Practice Address - Street 1:2900 BEDFORD AVE
Practice Address - Street 2:114 ROOSEVELT
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2850
Practice Address - Country:US
Practice Address - Phone:718-951-5580
Practice Address - Fax:718-951-5869
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420087363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health