Provider Demographics
NPI:1760535355
Name:FRASER-JOHNSON, JENNELYN VELMA (FNP)
Entity Type:Individual
Prefix:MS
First Name:JENNELYN
Middle Name:VELMA
Last Name:FRASER-JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 SCHENECTADY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1822
Mailing Address - Country:US
Mailing Address - Phone:718-604-5397
Mailing Address - Fax:718-604-5527
Practice Address - Street 1:585 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1822
Practice Address - Country:US
Practice Address - Phone:718-604-5397
Practice Address - Fax:718-604-5527
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333179363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF333179OtherNYS NP LICENSE