Provider Demographics
NPI:1598116972
Name:WANDASIEWICZ, JENNIFER (PNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WANDASIEWICZ
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 FULTON ST STE 4
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3601
Mailing Address - Country:US
Mailing Address - Phone:516-454-8525
Mailing Address - Fax:516-454-8130
Practice Address - Street 1:850 FULTON ST STE 4
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3601
Practice Address - Country:US
Practice Address - Phone:516-454-8525
Practice Address - Fax:516-454-8130
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382643363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics