Provider Demographics
NPI:1497364640
Name:MONGELLI, JESSICA MARIA (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIA
Last Name:MONGELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIA
Other - Last Name:ALVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3633 218TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2222
Mailing Address - Country:US
Mailing Address - Phone:917-628-9734
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1103
Practice Address - Country:US
Practice Address - Phone:516-708-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily