Healthcare Provider Details

I. General information

NPI: 1184391088
Provider Name (Legal Business Name): JACLYN NICOLE BOGGS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE BOGGS NP

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 197TH ST # 2
SAINT ALBANS NY
11412-3454
US

IV. Provider business mailing address

11714 197TH ST
SAINT ALBANS NY
11412-3454
US

V. Phone/Fax

Practice location:
  • Phone: 772-267-0331
  • Fax:
Mailing address:
  • Phone: 612-568-3843
  • Fax: 915-277-3221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number348277
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2681020
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberLG-0013731
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704441979APP26
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number204604
License Number StateND
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA193176
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53-85627-081
License Number StateKS
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11045668
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.1001762-NP
License Number StateCO
# 10
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP261398
License Number StateME
# 11
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12.018059
License Number StateCT
# 12
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-287365
License Number StateMT
# 13
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.035226
License Number StateIL
# 14
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-6027
License Number StateHI
# 15
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-RNP337884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: