Provider Demographics
NPI:1356612865
Name:POLANCO, BENNY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 LORING PL N
Mailing Address - Street 2:# 3
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5800
Mailing Address - Country:US
Mailing Address - Phone:646-483-9359
Mailing Address - Fax:
Practice Address - Street 1:2299 LORING PL N
Practice Address - Street 2:# 3
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5800
Practice Address - Country:US
Practice Address - Phone:646-483-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY476589163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse