Provider Demographics
NPI:1245297167
Name:WALLACE-LEVY, BRENDA (PA)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:WALLACE-LEVY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COMMUNITY DRIVE
Mailing Address - Street 2:NSUH-DEPT. OF NEUROSURGERY
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030
Mailing Address - Country:US
Mailing Address - Phone:516-562-3020
Mailing Address - Fax:
Practice Address - Street 1:972 BRUSH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1740
Practice Address - Country:US
Practice Address - Phone:516-876-5555
Practice Address - Fax:516-876-5539
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002813207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery