Healthcare Provider Details

I. General information

NPI: 1053748699
Provider Name (Legal Business Name): JENNIFER LYNN MAHEDY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNIFER LYNN VAZQUEZ

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 DUBOIS STREET ST LUKES HOSPITAL
NEWBURGH NY
12550
US

IV. Provider business mailing address

109 DENNISTON DRIVE
NEW WINDSOR NY
12553
US

V. Phone/Fax

Practice location:
  • Phone: 845-561-4400
  • Fax:
Mailing address:
  • Phone: 845-779-2804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number553704
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number553704-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number93724
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: