Provider Demographics
NPI:1679649412
Name:GAGNE, JENNIFER ANN (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:GAGNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:CASTELLANOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:147 BEACH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1733
Mailing Address - Country:US
Mailing Address - Phone:631-288-7746
Mailing Address - Fax:631-288-7111
Practice Address - Street 1:147 BEACH RD
Practice Address - Street 2:SUITE A
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-1733
Practice Address - Country:US
Practice Address - Phone:631-288-7746
Practice Address - Fax:631-288-7111
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302476-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P47675Medicare UPIN
NY2E5051Medicare ID - Type Unspecified