Healthcare Provider Details

I. General information

NPI: 1588066468
Provider Name (Legal Business Name): JESSICA M KOSTREWA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA M VAIL NP

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 BROCKTON DR
LOCKPORT NY
14094-9273
US

IV. Provider business mailing address

199 PARK CLUB LN STE 500
WILLIAMSVILLE NY
14221-5269
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-3400
  • Fax: 716-438-1430
Mailing address:
  • Phone: 716-845-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306893
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF306893
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: