Provider Demographics
NPI:1902407083
Name:BRENNAN, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:BRENNAN
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 1:18 RODERICK RD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2616
Mailing Address - Country:US
Mailing Address - Phone:631-422-3356
Mailing Address - Fax:
Practice Address - Street 1:BRENTWOOD UNION FREE SCHOOL DISTRICT
Practice Address - Street 2:2 SIXTH AVENUE
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-434-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY470769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty