Provider Demographics
NPI:1588656441
Name:VENGRIN, JANA GALE (NP)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:GALE
Last Name:VENGRIN
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 1:7875 ALBANY POST ROAD
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571
Mailing Address - Country:US
Mailing Address - Phone:845-594-5229
Mailing Address - Fax:
Practice Address - Street 1:7875 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-2147
Practice Address - Country:US
Practice Address - Phone:845-758-8101
Practice Address - Fax:845-758-8102
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400818-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF400818-1OtherNYS NP LICENSE
NYF400818-1OtherNYS NP LICENSE
NYMV1062722OtherDEA LICENSE