Provider Demographics
NPI:1619441748
Name:SMALL, JENNIFER W (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:SMALL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18706 ROME DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2607
Mailing Address - Country:US
Mailing Address - Phone:917-841-9256
Mailing Address - Fax:
Practice Address - Street 1:5916 174TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1539
Practice Address - Country:US
Practice Address - Phone:917-841-9256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342248-12080P0214X
NY342248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology