Basic Information
| Provider Information | |||||||||
| NPI: | 1174753743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRATHWAITE | ||||||||
| FirstName: | JILLENE | ||||||||
| MiddleName: | MYRNELLE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 ARCH ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636092 | ||||||||
| FaxNumber: | 6077636677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 07/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 254046 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 254046 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RE0101X | 254046 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 03128012 | 05 | NY | MEDICAID |