Healthcare Provider Details

I. General information

NPI: 1568911873
Provider Name (Legal Business Name): JENNIFER REILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 12/07/2025
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E. 74TH ST.
NEW YORK NY
10021
US

IV. Provider business mailing address

530 E. 74TH ST.
NEW YORK NY
10021
US

V. Phone/Fax

Practice location:
  • Phone: 631-682-3018
  • Fax:
Mailing address:
  • Phone: 631-682-3018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number310491
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: