Healthcare Provider Details

I. General information

NPI: 1790191708
Provider Name (Legal Business Name): JESSICA STILES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26901 76TH AVE 4TH FLOOR
NEW HYDE PARK NY
11040-1433
US

IV. Provider business mailing address

395 S END AVE APT 25B
NEW YORK NY
10280-1033
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-3140
  • Fax:
Mailing address:
  • Phone: 203-536-2295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0218X
TaxonomyPediatric Oncology Registered Nurse
License Number629734
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number382608
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: