Healthcare Provider Details

I. General information

NPI: 1982068441
Provider Name (Legal Business Name): JACQUELYN MARY SIVERLING LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 E MAIN STREET RD
BATAVIA NY
14020-3496
US

IV. Provider business mailing address

5130 E MAIN STREET RD
BATAVIA NY
14020-3496
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-1421
  • Fax: 585-345-3080
Mailing address:
  • Phone: 585-344-1421
  • Fax: 585-345-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number308530-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22-728422
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: