Healthcare Provider Details

I. General information

NPI: 1174024061
Provider Name (Legal Business Name): JENNIFER E GELSOMINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 34TH ST APT 2R
ASTORIA NY
11106-1212
US

IV. Provider business mailing address

3412 34TH ST APT 2R
ASTORIA NY
11106-1212
US

V. Phone/Fax

Practice location:
  • Phone: 631-258-5302
  • Fax:
Mailing address:
  • Phone: 631-258-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: