Provider Demographics
NPI:1447775747
Name:SONNENBERG, JENNA LAUREN
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LAUREN
Last Name:SONNENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ROUTE 25A STE C
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 ROUTE 25A STE C
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1389
Practice Address - Country:US
Practice Address - Phone:631-744-3303
Practice Address - Fax:631-744-1627
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308262363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health