Provider Demographics
NPI:1023339090
Name:WHITTAM, JENNILYN P (NP)
Entity type:Individual
Prefix:
First Name:JENNILYN
Middle Name:P
Last Name:WHITTAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 MALDEN TPKE
Mailing Address - Street 2:
Mailing Address - City:SAUGERTIES
Mailing Address - State:NY
Mailing Address - Zip Code:12477-5021
Mailing Address - Country:US
Mailing Address - Phone:845-616-3023
Mailing Address - Fax:
Practice Address - Street 1:41 CASTLE POINT RD
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-7004
Practice Address - Country:US
Practice Address - Phone:845-831-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03240420Medicaid
NYA400031314Medicare PIN