Provider Demographics
NPI:1881186930
Name:WADSWORTH, BRANDY LEE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:WADSWORTH
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 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4447
Mailing Address - Country:US
Mailing Address - Phone:518-926-6992
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:79 NORTH ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:NY
Practice Address - Zip Code:12832
Practice Address - Country:US
Practice Address - Phone:518-642-0612
Practice Address - Fax:518-642-0693
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY597823163W00000X
NY402434363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse