Provider Demographics
NPI:1558729988
Name:REILLY, BRENDA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MILLS ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-3722
Mailing Address - Country:US
Mailing Address - Phone:917-593-8728
Mailing Address - Fax:
Practice Address - Street 1:104 MILLS ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-3722
Practice Address - Country:US
Practice Address - Phone:917-593-8728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307230363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner