Healthcare Provider Details

I. General information

NPI: 1235528035
Provider Name (Legal Business Name): JACQUELINE GUILLAUME MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9595 CASERTA ST
LAKE WORTH FL
33467-5220
US

IV. Provider business mailing address

9595 CASERTA ST
LAKE WORTH FL
33467-5220
US

V. Phone/Fax

Practice location:
  • Phone: 561-641-7476
  • Fax:
Mailing address:
  • Phone: 561-641-7476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number107725
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: