Provider Demographics
NPI:1144791013
Name:VASCONEZ, JENNIFER (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VASCONEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 HARDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1111
Mailing Address - Country:US
Mailing Address - Phone:845-313-4054
Mailing Address - Fax:
Practice Address - Street 1:25 S MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-4917
Practice Address - Country:US
Practice Address - Phone:845-499-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily