Healthcare Provider Details

I. General information

NPI: 1053044941
Provider Name (Legal Business Name): MS. JENIFER NATALIE CLEMENTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

485 LOCKWOOD DR
SHIRLEY NY
11967-1117
US

IV. Provider business mailing address

485 LOCKWOOD DR
SHIRELY NY
11967
US

V. Phone/Fax

Practice location:
  • Phone: 631-806-4181
  • Fax:
Mailing address:
  • Phone: 631-806-4181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number459617
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: