Healthcare Provider Details

I. General information

NPI: 1962129577
Provider Name (Legal Business Name): JESSICA ROSE URBANK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

IV. Provider business mailing address

5400 S PARK AVE APT R4
HAMBURG NY
14075-3057
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF349120-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: