Provider Demographics
NPI:1023599107
Name:SMITH, JENNIFER ROMAINE (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROMAINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ROMAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:835 BROADWAY AVE APT 16B
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4925
Mailing Address - Country:US
Mailing Address - Phone:631-375-3005
Mailing Address - Fax:
Practice Address - Street 1:19 FOREST LN
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3140
Practice Address - Country:US
Practice Address - Phone:631-375-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY701898163WG0000X, 163WP0807X, 163WP0808X, 163WP0809X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult