Provider Demographics
NPI:1669846655
Name:GORGONE, BRONWYN
Entity type:Individual
Prefix:
First Name:BRONWYN
Middle Name:
Last Name:GORGONE
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 1:5 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5098
Mailing Address - Country:US
Mailing Address - Phone:631-235-6884
Mailing Address - Fax:
Practice Address - Street 1:655 MIDDLE COUNTRY RD APT 1E1
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3337
Practice Address - Country:US
Practice Address - Phone:631-235-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705261163W00000X
NYF421511363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse