Healthcare Provider Details

I. General information

NPI: 1770111833
Provider Name (Legal Business Name): JILLIAN YACENDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PARK AVE
HUNTINGTON NY
11743-4543
US

IV. Provider business mailing address

26 BEATTY AVE
GREENLAWN NY
11740-2502
US

V. Phone/Fax

Practice location:
  • Phone: 631-271-5800
  • Fax:
Mailing address:
  • Phone: 516-356-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number759464
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: