Provider Demographics
NPI:1518541929
Name:PACE, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:PACE
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 1:1132 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1622
Mailing Address - Country:US
Mailing Address - Phone:516-880-4414
Mailing Address - Fax:
Practice Address - Street 1:1132 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-1622
Practice Address - Country:US
Practice Address - Phone:516-880-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 2255A2300X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer