Provider Demographics
NPI:1679128904
Name:CASILLA, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CASILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CASILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:148 BURNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-1335
Mailing Address - Country:US
Mailing Address - Phone:631-494-5966
Mailing Address - Fax:
Practice Address - Street 1:148 BURNEY BLVD
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-1335
Practice Address - Country:US
Practice Address - Phone:631-494-5966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309348-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health