Healthcare Provider Details

I. General information

NPI: 1053388801
Provider Name (Legal Business Name): JESSICA ANN KOSCELNAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA ANN DIBBLE FNP

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MITCHELL AVENUE
BINGHAMTON NY
13903
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2558
US

V. Phone/Fax

Practice location:
  • Phone: 607-772-0639
  • Fax: 607-722-4610
Mailing address:
  • Phone: 607-763-6293
  • Fax: 607-763-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334804
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: