Provider Demographics
NPI:1144791013
Name:VASCONEZ, JENNIFER (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VASCONEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22239
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-0001
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:30 CRAGMERE RD
Practice Address - Street 2:
Practice Address - City:AIRMONT
Practice Address - State:NY
Practice Address - Zip Code:10901-7520
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:702-977-1496
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06302203Medicaid