Healthcare Provider Details

I. General information

NPI: 1720170061
Provider Name (Legal Business Name): JACQUELINE OLIVIERI RPAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 N MAIN ST
FREEPORT NY
11520-2243
US

IV. Provider business mailing address

55 N MAIN ST
FREEPORT NY
11520-2243
US

V. Phone/Fax

Practice location:
  • Phone: 516-377-8014
  • Fax: 516-377-8017
Mailing address:
  • Phone: 516-377-8014
  • Fax: 516-377-8017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010927
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: