Provider Demographics
NPI:1558010454
Name:PROVENZANO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BONITA LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-3602
Mailing Address - Country:US
Mailing Address - Phone:347-515-9237
Mailing Address - Fax:
Practice Address - Street 1:2400 BONITA LN
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-3602
Practice Address - Country:US
Practice Address - Phone:347-515-9237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-20
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care