Provider Demographics
NPI:1891849618
Name:RAVEENDRANATH, BROOKE A (NP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:RAVEENDRANATH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:6 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3791
Practice Address - Country:US
Practice Address - Phone:518-641-6319
Practice Address - Fax:518-641-6850
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY381788363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848268Medicaid
NY000420465001OtherBSNENY
NY3010992OtherMVP HEALTHCARE
NY143259OtherGHI-HMO
NY091210000047OtherFIDELIS
NYJ400010322Medicare PIN