Provider Demographics
NPI:1669136339
Name:SANTAMARIA, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SANTAMARIA
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 1:125 OAKLAND AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2130
Mailing Address - Country:US
Mailing Address - Phone:631-686-2565
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD # T16-080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-2130
Practice Address - Country:US
Practice Address - Phone:631-444-1066
Practice Address - Fax:631-444-1054
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310414363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health