Healthcare Provider Details

I. General information

NPI: 1366520389
Provider Name (Legal Business Name): JESSICA LILA PONIATOWSKI APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 HAMBURG TPKE SUITE 201
WAYNE NJ
07470-2025
US

IV. Provider business mailing address

510 HAMBURG TPKE SUITE 201
WAYNE NJ
07470-2025
US

V. Phone/Fax

Practice location:
  • Phone: 973-942-1141
  • Fax: 973-942-7071
Mailing address:
  • Phone: 973-942-1141
  • Fax: 973-942-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00090600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: