=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376278465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BIELAWA AGPCNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2022
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 MAIN RD
-----------------------------------------------------
City | CORFU
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14036-9753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-599-6446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11466 CARY RD
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-9597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | F310718-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------