Provider Demographics
NPI:1558102533
Name:SIOSON, JOMELYN BERNADETTE PROVIDO
Entity type:Individual
Prefix:
First Name:JOMELYN BERNADETTE
Middle Name:PROVIDO
Last Name:SIOSON
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 1:9428 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5147
Mailing Address - Country:US
Mailing Address - Phone:917-497-9159
Mailing Address - Fax:
Practice Address - Street 1:9428 57TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5147
Practice Address - Country:US
Practice Address - Phone:917-497-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY760314163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool