Provider Demographics
NPI:1356813653
Name:ENDERLINE, JENNIFER MARIE (AG-ACNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:ENDERLINE
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:169 MADISON AVE STE 2817
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5101
Mailing Address - Country:US
Mailing Address - Phone:888-553-2823
Mailing Address - Fax:888-553-2823
Practice Address - Street 1:169 MADISON AVE STE 2817
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5101
Practice Address - Country:US
Practice Address - Phone:888-553-2823
Practice Address - Fax:888-553-2823
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433088363LA2100X
FLAPRN11028038363LA2100X
MI4704407614363LA2100X
TX1141255363LA2100X
AZ220412363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356813653Medicaid