Provider Demographics
NPI:1457958118
Name:KACZMAREK, BRIAN LUCAS (RN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LUCAS
Last Name:KACZMAREK
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 1:135 CORSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2933
Mailing Address - Country:US
Mailing Address - Phone:917-719-1885
Mailing Address - Fax:
Practice Address - Street 1:380 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3296
Practice Address - Country:US
Practice Address - Phone:718-984-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705571163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult