MEDICARE: COLLETTA LATOYA JERRICK NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F403813-01	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F403813-01	OTHER	NY	NEW YORK STATE OFFICE OF THE PROFESSIONS

General Provider Information

NPI Number	:	1922720887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLETTA LATOYA JERRICK NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1548 E FORKS RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-3144
Country	:	US
Telephone Number	:	631-308-7658
Fax Number	:

Provider Business Practice Location Address
First Line	:	1548 E FORKS RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-3144
Country	:	US
Telephone Number	:	631-308-7658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	09/16/2022

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