Provider Demographics
NPI:1942208343
Name:DELISA, JANE A (FNP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:DELISA
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 1:460 MAIN ST
Mailing Address - Street 2:STE 1Q
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2027
Mailing Address - Country:US
Mailing Address - Phone:607-433-0277
Mailing Address - Fax:607-432-1184
Practice Address - Street 1:460 MAIN ST
Practice Address - Street 2:STE 1Q
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2027
Practice Address - Country:US
Practice Address - Phone:607-433-0277
Practice Address - Fax:607-432-1184
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3302291164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
10024786OtherCDPHP
R75425Medicare UPIN
NYCC3079Medicare ID - Type Unspecified