Healthcare Provider Details

I. General information

NPI: 1932575578
Provider Name (Legal Business Name): JACLYN LEE CARNERALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLY LEE MANNION PA-C

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 AMSTERDAM AVE
NEW YORK NY
10023-7410
US

IV. Provider business mailing address

600 NORTHERN BLVD. SUITE #111
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 516-680-7538
  • Fax:
Mailing address:
  • Phone: 516-387-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number018929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: