Provider Demographics
NPI:1558341719
Name:BRUCKENTHAL, PATRICIA (NP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:BRUCKENTHAL
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 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:45 TERRY RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3894
Practice Address - Country:US
Practice Address - Phone:631-724-7246
Practice Address - Fax:631-724-6377
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340956164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02443167Medicaid
NYQ07427Medicare UPIN
NY02443167Medicaid