Provider Demographics
NPI:1861226706
Name:LAINE, JESSICA (FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAINE
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 1:11317 COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2218
Mailing Address - Country:US
Mailing Address - Phone:347-886-3101
Mailing Address - Fax:
Practice Address - Street 1:11317 COLFAX ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2218
Practice Address - Country:US
Practice Address - Phone:347-886-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF35495801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily