Provider Demographics
NPI:1902008238
Name:BRUNETTI, ELLEN
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:BRUNETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:DEMPSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 EAST ECKERSON ROAD
Mailing Address - Street 2:1-6
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-7153
Mailing Address - Country:US
Mailing Address - Phone:845-352-5900
Mailing Address - Fax:845-352-1142
Practice Address - Street 1:200 E ECKERSON RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-7153
Practice Address - Country:US
Practice Address - Phone:845-352-6936
Practice Address - Fax:845-352-3144
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333535363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113324002OtherTAX ID
NY1023189990OtherNPI