Organization
MODERN PSYCHIATRIC NURSE PRACTITIONER PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRIGHID GANNON (OWNER)
(212) 734-6621
Entity
Organization
Contact information
Practice address
1740 84TH ST, BROOKLYN, NY 11214-2825
(718) 855-8584
Mailing address
191 ORCHARD ST, APT. 4D, NEW YORK, NY 10002-1415
(718) 757-0684
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
F401646
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03793386
—
NY
01
—
A400097567
MEDICARE PTAN
NY
Enumeration date
09/14/2016
Last updated
01/19/2023
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