Provider Demographics
NPI:1063860138
Name:DELLASALA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DELLASALA
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 1:400 E 71ST ST
Mailing Address - Street 2:APT 23K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4808
Mailing Address - Country:US
Mailing Address - Phone:732-794-4419
Mailing Address - Fax:
Practice Address - Street 1:400 E 71ST ST
Practice Address - Street 2:APT 23K
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4808
Practice Address - Country:US
Practice Address - Phone:732-794-4419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 618371163W00000X
NY30 307236363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse