Healthcare Provider Details

I. General information

NPI: 1689578742
Provider Name (Legal Business Name): JENET DIPAK SISODIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 HARBOR RD
STATEN ISLAND NY
10303-1817
US

IV. Provider business mailing address

262 HARBOR RD
STATEN ISLAND NY
10303-1817
US

V. Phone/Fax

Practice location:
  • Phone: 347-909-6022
  • Fax:
Mailing address:
  • Phone: 347-951-4694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number74251201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: