Healthcare Provider Details

I. General information

NPI: 1972733426
Provider Name (Legal Business Name): KEISHA M JAQUAY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 VAN BUREN ST
DOLGEVILLE NY
13329-1360
US

IV. Provider business mailing address

66 VAN BUREN ST
DOLGEVILLE NY
13329-1360
US

V. Phone/Fax

Practice location:
  • Phone: 315-429-5058
  • Fax:
Mailing address:
  • Phone: 315-429-5058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number270002
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: