Healthcare Provider Details

I. General information

NPI: 1144363151
Provider Name (Legal Business Name): JENNIFER JOY FAGAN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 ROUTE 300 STE 102
NEWBURGH NY
12550-1738
US

IV. Provider business mailing address

17 WINCHESTER WAY
WASHINGTONVILLE NY
10992-1741
US

V. Phone/Fax

Practice location:
  • Phone: 845-564-9853
  • Fax: 845-564-6974
Mailing address:
  • Phone: 845-496-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number006651
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: