Provider Demographics
NPI:1952933624
Name:BERMUDEZ, JENNA (ANP-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2325
Mailing Address - Country:US
Mailing Address - Phone:631-807-2786
Mailing Address - Fax:
Practice Address - Street 1:421 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2313
Practice Address - Country:US
Practice Address - Phone:631-941-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309438-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty