Healthcare Provider Details

I. General information

NPI: 1295907905
Provider Name (Legal Business Name): CASSONDRA M MEJAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 07/06/2023
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE RGPA
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

1455 E RIDGE RD
ROCHESTER NY
14621-2006
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2575
  • Fax: 585-922-5033
Mailing address:
  • Phone: 585-922-2575
  • Fax: 585-922-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number563527
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number335570
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: