Healthcare Provider Details

I. General information

NPI: 1013631027
Provider Name (Legal Business Name): MS. WENCHELLE JEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9027 SUTPHIN BLVD STE 5
JAMAICA NY
11435-3648
US

IV. Provider business mailing address

47 JACKSON ST
FARMINGDALE NY
11735-6809
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number818329
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: