Provider Demographics
NPI:1982111803
Name:BURGENSTOCK, BREANNA LYNN
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LYNN
Last Name:BURGENSTOCK
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 1:20823 NYS RT 3
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20823 NYS RT 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5577
Practice Address - Country:US
Practice Address - Phone:315-788-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8463-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY207069530Medicaid
NY207069530Medicaid