Provider Demographics
NPI:1720390826
Name:JATA, TONI ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:TONI
Middle Name:ANN
Last Name:JATA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 BAYARD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3150
Mailing Address - Country:US
Mailing Address - Phone:631-467-3708
Mailing Address - Fax:
Practice Address - Street 1:69 BAYARD ST
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-3150
Practice Address - Country:US
Practice Address - Phone:631-467-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY618604163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse