Provider Demographics
NPI:1528552205
Name:HOUGHTALING-BRYDA, DAWN
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:HOUGHTALING-BRYDA
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:PO BOX 651
Mailing Address - Street 2:
Mailing Address - City:SMALLWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:12778-0651
Mailing Address - Country:US
Mailing Address - Phone:845-239-9812
Mailing Address - Fax:
Practice Address - Street 1:32 FOSTER RD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:NY
Practice Address - Zip Code:12786
Practice Address - Country:US
Practice Address - Phone:845-239-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271469-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse