Provider Demographics
NPI:1013278910
Name:MOFFAT, JENNY GINA
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:GINA
Last Name:MOFFAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 N QUEENS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3209
Mailing Address - Country:US
Mailing Address - Phone:516-659-0033
Mailing Address - Fax:
Practice Address - Street 1:535 8TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4305
Practice Address - Country:US
Practice Address - Phone:212-787-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY726122174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist