Healthcare Provider Details

I. General information

NPI: 1124994256
Provider Name (Legal Business Name): JADE HULL CMA, LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 E 4TH ST
DEER PARK NY
11729-4308
US

IV. Provider business mailing address

90 E 4TH ST
DEER PARK NY
11729-4308
US

V. Phone/Fax

Practice location:
  • Phone: 516-668-7482
  • Fax:
Mailing address:
  • Phone: 516-668-7482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number354202
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: