MEDICARE: JENNIFER WANDASIEWICZ PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	382643	NY

General Provider Information

NPI Number	:	1598116972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER WANDASIEWICZ PNP

Provider Business Mailing Address
First Line	:	850 FULTON ST STE 4
Second Line	:
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-3601
Country	:	US
Telephone Number	:	516-454-8525
Fax Number	:	516-454-8130

Provider Business Practice Location Address
First Line	:	850 FULTON ST STE 4
Second Line	:
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-3601
Country	:	US
Telephone Number	:	516-454-8525
Fax Number	:	516-454-8130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	04/29/2022

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