=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255847679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA FASSANO CPNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2017
-----------------------------------------------------
Last Update Date | 12/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26901 76TH AVE
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-470-3956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6822 MADELINE CT
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-5807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-808-5936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | F382804-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------