MEDICARE: JILLIAN MARIE KWAK

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	363LF0000X	Family Nurse Practitioner	354987	NY

General Provider Information

NPI Number	:	1992539845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN MARIE KWAK

Provider Business Mailing Address
First Line	:	315 E 86TH ST APT 2DE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4761
Country	:	US
Telephone Number	:	570-262-2476
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 E 86TH ST APT 2DE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4761
Country	:	US
Telephone Number	:	570-262-2476
Fax Number	:

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

Provider Enumeration Date	:	08/30/2024
Last Update Date	:	08/30/2024

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