Provider Demographics
NPI:1194063594
Name:BENNARDO, TRACEY (NP)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:BENNARDO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CEDARHURST ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-1037
Mailing Address - Country:US
Mailing Address - Phone:631-650-1625
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily