Healthcare Provider Details

I. General information

NPI: 1720381486
Provider Name (Legal Business Name): JACQUELINE L KILLEEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W HALLANDALE BEACH BLVD SUITE 200
HALLANDALE FL
33009-5155
US

IV. Provider business mailing address

3001 W HALLANDALE BEACH BLVD SUITE 200
HALLANDALE FL
33009-5155
US

V. Phone/Fax

Practice location:
  • Phone: 954-456-4888
  • Fax: 954-456-9721
Mailing address:
  • Phone: 954-456-4888
  • Fax: 954-456-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberARNP 3066702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: