Healthcare Provider Details

I. General information

NPI: 1376278465
Provider Name (Legal Business Name): JESSICA BIELAWA AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 MAIN RD
CORFU NY
14036-9753
US

IV. Provider business mailing address

11466 CARY RD
ALDEN NY
14004-9597
US

V. Phone/Fax

Practice location:
  • Phone: 585-599-6446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF310718-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: