Provider Demographics
NPI:1629330741
Name:FYDELL, JENNIFER M (MSED)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:FYDELL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 W END AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6415
Mailing Address - Country:US
Mailing Address - Phone:516-946-2298
Mailing Address - Fax:
Practice Address - Street 1:274 W END AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6415
Practice Address - Country:US
Practice Address - Phone:516-946-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1672997174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist