Provider Demographics
NPI:1144096926
Name:FATALE, JESSICA MARIE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:FATALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ELM PL
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3000
Mailing Address - Country:US
Mailing Address - Phone:917-715-9301
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14967000363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal