Provider Demographics
NPI:1639491202
Name:BRILLIANT-MARY, JEANINE
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:
Last Name:BRILLIANT-MARY
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 1:1039 OCEAN AVE
Mailing Address - Street 2:APT 8
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-7487
Mailing Address - Country:US
Mailing Address - Phone:917-561-3564
Mailing Address - Fax:
Practice Address - Street 1:1039 OCEAN AVE
Practice Address - Street 2:APT 8
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7487
Practice Address - Country:US
Practice Address - Phone:917-561-3564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247520164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse