Provider Demographics
NPI:1699313288
Name:VALENZUELA, BRUNO JESUS
Entity type:Individual
Prefix:
First Name:BRUNO
Middle Name:JESUS
Last Name:VALENZUELA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1605
Mailing Address - Country:US
Mailing Address - Phone:631-332-0545
Mailing Address - Fax:
Practice Address - Street 1:1 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1605
Practice Address - Country:US
Practice Address - Phone:631-332-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336868164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse