Provider Demographics
NPI:1972934503
Name:BERNOCK, KATHLEEN (FNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BERNOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2505
Mailing Address - Country:US
Mailing Address - Phone:718-636-4500
Mailing Address - Fax:347-296-8308
Practice Address - Street 1:1456 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2505
Practice Address - Country:US
Practice Address - Phone:718-636-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-08
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY657168-1163W00000X
NYF339362-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse