Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 343713 | NY |
NPI | 1003380528 |
---|---|
Provider Name | Jessica Lynn Hafezi |
First Address | Buffalo, NY 14263-0001 |
Second Address | Buffalo, NY 14263-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2019 |
Last Update Date | 14/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
343713 | NP-NYS LICENSE (01) | NY |