Provider Demographics
NPI:1154840973
Name:WACHTELHAUSEN, JESSINA ROSE (RN)
Entity Type:Individual
Prefix:
First Name:JESSINA
Middle Name:ROSE
Last Name:WACHTELHAUSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JESSINA
Other - Middle Name:ROSE
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:110 W 97TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6450
Mailing Address - Country:US
Mailing Address - Phone:212-316-7906
Mailing Address - Fax:212-932-8323
Practice Address - Street 1:110 W 97TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6450
Practice Address - Country:US
Practice Address - Phone:212-316-7906
Practice Address - Fax:212-932-8323
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY549420163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse