Healthcare Provider Details

I. General information

NPI: 1740839299
Provider Name (Legal Business Name): JACQUELINE R PERRY-STEWART RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 BLOSSOM RD
ROCHESTER NY
14610-1807
US

IV. Provider business mailing address

75 FERRIS ST
ROCHESTER NY
14609-4854
US

V. Phone/Fax

Practice location:
  • Phone: 315-450-1783
  • Fax:
Mailing address:
  • Phone: 315-450-1783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number949817
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number334977
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: