Healthcare Provider Details

I. General information

NPI: 1134035009
Provider Name (Legal Business Name): JACQUELINE LEA VAN VLIET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

1346 PACIFIC ST APT 3A
BROOKLYN NY
11216-6838
US

V. Phone/Fax

Practice location:
  • Phone: 315-391-1278
  • Fax:
Mailing address:
  • Phone: 315-391-1278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF433469
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: