Most Relevant Information
Provider Data
| NPI Number: | 1003249020 |
| Provider Name: | JENNIFER DISLA |
| Entity Type: | Individual |
| Taxonomy Code: | 174400000X |
| Specialty: | Specialist |
| License Number: | 1191109 |
Most Important Dates
| Enumeration Date: | 08/13/2013 |
| Last Updated: | 08/13/2013 |
Provider Practice Location
11172 42ND AVE
CORONA
NY
113682620
Practice Location Phone/Fax
| Phone: | 7184580571 |
| Fax: |
Provider Mailing Location
111-72 42ND AVENUE
CORONA
MT
11368
Provider Mailing Phone/Fax
| Phone: | 7184580571 |
| Fax: |