Provider Demographics
NPI:1619513900
Name:DALISTAN, JANINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:DALISTAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9414
Mailing Address - Country:US
Mailing Address - Phone:585-465-7464
Mailing Address - Fax:
Practice Address - Street 1:113 SEABOARD LN STE 200B
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8282
Practice Address - Country:US
Practice Address - Phone:855-292-7957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352337363LF0000X
NY708439163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse