Provider Demographics
NPI:1164527164
Name:GRELLA, JENNIFER ANNE (APRN,BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:GRELLA
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:MABEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 ASTER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1733
Mailing Address - Country:US
Mailing Address - Phone:631-207-2262
Mailing Address - Fax:631-207-2262
Practice Address - Street 1:363 ROUTE 111
Practice Address - Street 2:SUITE 101
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4756
Practice Address - Country:US
Practice Address - Phone:631-724-8075
Practice Address - Fax:631-724-8076
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303036-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health