MEDICARE: DANIELLE ELAINE JERNIGAN RN

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	163W00000X	Registered Nurse	702642	NY

General Provider Information

NPI Number	:	1942080973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE ELAINE JERNIGAN RN

Provider Business Mailing Address
First Line	:	596 TOMPKINS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-3030
Country	:	US
Telephone Number	:	347-698-7384
Fax Number	:

Provider Business Practice Location Address
First Line	:	596 TOMPKINS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-3030
Country	:	US
Telephone Number	:	347-698-7384
Fax Number	:

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

Provider Enumeration Date	:	10/05/2023
Last Update Date	:	10/05/2023

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