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General NPI Number Information
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NPI Number | 1003249020
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Entity Type | Individual
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Provider Name | MISS JENNIFER DISLA
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Gender | Female
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Dates
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Enumeration Date | 08/13/2013
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Last Update Date | 08/13/2013
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Provider Practice Location Address
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Address Line | 11172 42ND AVE
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City | CORONA
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State | NY
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Zip | 11368-2620
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Country | US
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Telephone | 718-458-0571
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Fax |
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Provider Business Mailing Address
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Address Line | 111-72 42ND AVENUE
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City | CORONA
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State | MT
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Zip | 11368
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Country | US
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Telephone | 718-458-0571
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 1191109
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License Number State | NY
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