Basic Information
Provider Information | |||||||||
NPI: | 1336114453 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | BERNADETTE | ||||||||
MiddleName: | N. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC, PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8011 AVENUE K | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112364201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5616282860 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1400 PELHAM PARKWAY SOUTH | ||||||||
Address2: | JACOBI MEDICAL CENTER | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 10461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189185000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 11/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9209602 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | F333417 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 306640100 | 05 | NY |   | MEDICAID | Y064G | 01 | NY | MEDICARE ID UNSPECIFIED | OTHER | Y064X | 01 | NY | MEDICARE ID UNSPECIFIED | OTHER | Y064Y | 01 | NY | MEDICARE ID UNSPECIFIED | OTHER |