Provider Demographics
NPI:1770666117
Name:JANOTHA, BRENDA LYNN
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:JANOTHA
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 1:3392 LUFBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3006
Mailing Address - Country:US
Mailing Address - Phone:516-781-6512
Mailing Address - Fax:
Practice Address - Street 1:994 W JERICHO TPKE
Practice Address - Street 2:SUITE 201
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3235
Practice Address - Country:US
Practice Address - Phone:631-864-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302705-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP97010Medicare UPIN