Provider Demographics
NPI:1770030348
Name:DELANG, JENNIE LYNNE (RN)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LYNNE
Last Name:DELANG
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 1:1000 ELMWOOD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVE.
Practice Address - Street 2:100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-271-2897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY697594-01163WS0200X
NY6975941163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1770030348Medicaid