Provider Demographics
NPI:1700549276
Name:BISTANY, BRANDY ANN
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:ANN
Last Name:BISTANY
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 1:30 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2171
Mailing Address - Country:US
Mailing Address - Phone:516-639-4968
Mailing Address - Fax:
Practice Address - Street 1:30 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2171
Practice Address - Country:US
Practice Address - Phone:516-639-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018332225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist