Provider Demographics
NPI:1699809541
Name:PONTILLO, BRENDA JEAN (NP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:PONTILLO
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 1:251 FORT WASHINGTON AVE APT 46
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1248
Mailing Address - Country:US
Mailing Address - Phone:734-883-7967
Mailing Address - Fax:
Practice Address - Street 1:21 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2275
Practice Address - Country:US
Practice Address - Phone:929-715-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704188594363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner