Provider Demographics
NPI:1932808128
Name:WHITTALL, BRENT (RN)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WHITTALL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 UNION RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1851
Mailing Address - Country:US
Mailing Address - Phone:716-505-5700
Mailing Address - Fax:
Practice Address - Street 1:4635 UNION RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-1851
Practice Address - Country:US
Practice Address - Phone:716-505-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723503163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool