Provider Demographics
NPI:1902004559
Name:BAIN, PHYLLIS ALEXANDRIA (NP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ALEXANDRIA
Last Name:BAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 NEWKIRK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6613
Mailing Address - Country:US
Mailing Address - Phone:718-469-0416
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:BUILDING E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-3267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420296363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner