Provider Demographics
NPI:1053972034
Name:CAVALLARO, JENNIFER (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CAVALLARO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 N MAIN ST STE 100B
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1661
Mailing Address - Country:US
Mailing Address - Phone:315-458-4623
Mailing Address - Fax:
Practice Address - Street 1:792 N MAIN ST STE 100B
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1661
Practice Address - Country:US
Practice Address - Phone:315-458-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily