Provider Demographics
NPI:1720411887
Name:BRONG, JEREMY STEPHEN (LPN)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:STEPHEN
Last Name:BRONG
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GRANGE PL
Mailing Address - Street 2:APT B
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1332
Mailing Address - Country:US
Mailing Address - Phone:607-749-0267
Mailing Address - Fax:
Practice Address - Street 1:5 GRANGE PL
Practice Address - Street 2:APT B
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1332
Practice Address - Country:US
Practice Address - Phone:607-749-0267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300034-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse