Provider Demographics
NPI:1518415983
Name:MODERN PSYCHIATRIC NURSE PRACTITIONER PC
Entity Type:Organization
Organization Name:MODERN PSYCHIATRIC NURSE PRACTITIONER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIGHID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-734-6621
Mailing Address - Street 1:191 ORCHARD ST
Mailing Address - Street 2:APT. 4D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-1415
Mailing Address - Country:US
Mailing Address - Phone:718-757-0684
Mailing Address - Fax:
Practice Address - Street 1:1740 84TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2825
Practice Address - Country:US
Practice Address - Phone:718-855-8584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401646363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03793386Medicaid
NYA400097567OtherMEDICARE PTAN