Provider Demographics
NPI:1699443408
Name:GILISTRO, JAMIE ROSE (FNP)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:ROSE
Last Name:GILISTRO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3643
Mailing Address - Country:US
Mailing Address - Phone:631-553-2926
Mailing Address - Fax:
Practice Address - Street 1:46 PINE BLVD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3643
Practice Address - Country:US
Practice Address - Phone:631-553-2926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348203-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily