Provider Demographics
NPI:1407416035
Name:PHELABAUM, JENNIFER H (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:PHELABAUM
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 1:203 OLD MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1738
Mailing Address - Country:US
Mailing Address - Phone:518-523-1717
Mailing Address - Fax:
Practice Address - Street 1:203 OLD MILITARY RD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1738
Practice Address - Country:US
Practice Address - Phone:518-523-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily