Healthcare Provider Details

I. General information

NPI: 1053215921
Provider Name (Legal Business Name): GISSEL JEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

86 SIMONSON PL
STATEN ISLAND NY
10302-1816
US

IV. Provider business mailing address

86 SIMONSON PL
STATEN ISLAND NY
10302-1816
US

V. Phone/Fax

Practice location:
  • Phone: 347-356-8342
  • Fax: 999-999-9999
Mailing address:
  • Phone: 347-356-8342
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number357029-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: