Provider Demographics
NPI:1053388801
Name:KOSCELNAK, JESSICA ANN (FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:KOSCELNAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:DIBBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-763-6293
Mailing Address - Fax:607-763-6717
Practice Address - Street 1:40 MITCHELL AVENUE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903
Practice Address - Country:US
Practice Address - Phone:607-772-0639
Practice Address - Fax:607-722-4610
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02728150Medicaid
NYRB9782Medicare PIN