Healthcare Provider Details

I. General information

NPI: 1700135019
Provider Name (Legal Business Name): MISS JESSICA J MONACO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 NESCONSET HWY BLDG 6 SUITE 30
PORT JEFF STA NY
11776-2053
US

IV. Provider business mailing address

20 CAROL DR
LAKE RONKONKOMA NY
11779-2705
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-4284
  • Fax:
Mailing address:
  • Phone: 631-793-3575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number864859
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: