Healthcare Provider Details

I. General information

NPI: 1508475468
Provider Name (Legal Business Name): JESSICA TRENTACOSTE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LAKEVILLE RD STE 107
NEW HYDE PARK NY
11042-1102
US

IV. Provider business mailing address

67 MAPLE AVE
FLORAL PARK NY
11001-2510
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-5400
  • Fax: 516-465-5454
Mailing address:
  • Phone: 516-662-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF346188-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: