Provider Demographics
NPI:1003249020
Name:DISLA, JENNIFER
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:DISLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111-72 42ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:MT
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-458-0571
Mailing Address - Fax:
Practice Address - Street 1:11172 42ND AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2620
Practice Address - Country:US
Practice Address - Phone:718-458-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1191109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist