Healthcare Provider Details

I. General information

NPI: 1093268740
Provider Name (Legal Business Name): JENNIFER KIM LY LLANOS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 VERNON BLVD
LONG ISLAND CITY NY
11106-4927
US

IV. Provider business mailing address

3250 VERNON BLVD
LONG ISLAND CITY NY
11106-4927
US

V. Phone/Fax

Practice location:
  • Phone: 718-267-3687
  • Fax:
Mailing address:
  • Phone: 718-267-3687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9003T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: