Healthcare Provider Details

I. General information

NPI: 1699247411
Provider Name (Legal Business Name): JESSICA ERIN HENZLER RN,BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 TACOMA AVE
BUFFALO NY
14216-2335
US

IV. Provider business mailing address

140 TACOMA AVE
BUFFALO NY
14216-2335
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-4065
  • Fax:
Mailing address:
  • Phone: 716-816-4065
  • Fax: 716-871-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number616766
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: