Healthcare Provider Details

I. General information

NPI: 1023602182
Provider Name (Legal Business Name): JANNINE WAIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5254 MERRICK RD STE 18
MASSAPEQUA NY
11758-6206
US

IV. Provider business mailing address

138 FORD ST
BOONVILLE NY
13309-1217
US

V. Phone/Fax

Practice location:
  • Phone: 754-444-2136
  • Fax:
Mailing address:
  • Phone: 754-444-2136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number028629-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: