Provider Demographics
NPI:1558745018
Name:GANNON, BRITTANY NICOLE (PHD, MSN, AGPCNP-BC)
Entity Type:Individual
Prefix:DR
First Name:BRITTANY
Middle Name:NICOLE
Last Name:GANNON
Suffix:
Gender:F
Credentials:PHD, MSN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4103
Mailing Address - Country:US
Mailing Address - Phone:212-326-5705
Mailing Address - Fax:212-342-0093
Practice Address - Street 1:516 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4103
Practice Address - Country:US
Practice Address - Phone:212-326-5705
Practice Address - Fax:212-342-0093
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9343603363L00000X
NY309024363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIG614ZMedicare PIN