Provider Demographics
NPI:1639485022
Name:SPORN, BRENDA (FNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SPORN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:125-06 101ST AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419
Practice Address - Country:US
Practice Address - Phone:718-849-2900
Practice Address - Fax:718-559-5468
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584123-1251S00000X
NY339449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No251S00000XAgenciesCommunity/Behavioral Health