Provider Demographics
NPI:1407532930
Name:MIANULLI, JESSICA RENEE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:MIANULLI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:RENNE
Other - Last Name:MIANULLI
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:254 NORMA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1514
Mailing Address - Country:US
Mailing Address - Phone:516-567-5790
Mailing Address - Fax:
Practice Address - Street 1:254 NORMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-1514
Practice Address - Country:US
Practice Address - Phone:516-567-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist