Provider Demographics
NPI:1699229427
Name:BRODSKY, BREANNA CLAIRE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:CLAIRE
Last Name:BRODSKY
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 1:56 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2632
Mailing Address - Country:US
Mailing Address - Phone:716-297-0798
Mailing Address - Fax:716-297-0998
Practice Address - Street 1:56 MARILYN DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2632
Practice Address - Country:US
Practice Address - Phone:716-297-0798
Practice Address - Fax:716-297-0998
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1402313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1402313OtherNEW YORK STATE LICENSE