Provider Demographics
NPI:1114044336
Name:DENNIS, JEDIDAH DENISE (NP)
Entity Type:Individual
Prefix:MS
First Name:JEDIDAH
Middle Name:DENISE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1004
Mailing Address - Country:US
Mailing Address - Phone:716-878-6711
Mailing Address - Fax:716-878-6727
Practice Address - Street 1:1300 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1004
Practice Address - Country:US
Practice Address - Phone:716-878-6711
Practice Address - Fax:716-878-6727
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302256363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY302256OtherLIC