Provider Demographics
NPI:1508077058
Name:FIDELO, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FIDELO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 W JERICHO TPKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3235
Mailing Address - Country:US
Mailing Address - Phone:631-474-5800
Mailing Address - Fax:631-864-9201
Practice Address - Street 1:994 W JERICHO TPKE
Practice Address - Street 2:SUITE 202
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3235
Practice Address - Country:US
Practice Address - Phone:631-474-5800
Practice Address - Fax:631-864-9201
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant