Provider Demographics
NPI:1619415031
Name:BRISTOL, ROSALYNN
Entity Type:Individual
Prefix:
First Name:ROSALYNN
Middle Name:
Last Name:BRISTOL
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 1:33 TOWN HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1162
Mailing Address - Country:US
Mailing Address - Phone:917-440-6743
Mailing Address - Fax:
Practice Address - Street 1:33 TOWN HOUSE DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1162
Practice Address - Country:US
Practice Address - Phone:917-440-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency