Provider Demographics
NPI:1831883404
Name:VANDYK, BREANNA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:VANDYK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:140 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2607
Practice Address - Country:US
Practice Address - Phone:845-563-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2025-03-11
Deactivation Date:2024-12-13
Deactivation Code:
Reactivation Date:2025-01-28
Provider Licenses
StateLicense IDTaxonomies
NY355846363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily