Healthcare Provider Details

I. General information

NPI: 1831822444
Provider Name (Legal Business Name): ALISA JAGANJAC CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

3364 21ST ST APT 15A
LONG ISLAND CITY NY
11106-4262
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-3391
  • Fax:
Mailing address:
  • Phone: 917-912-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number1135987DUP
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: