Healthcare Provider Details

I. General information

NPI: 1013411388
Provider Name (Legal Business Name): JACQUELINE SIERRA COPPOLA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE SIERRA COPPOLA

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2546 BALLTOWN RD
SCHENECTADY NY
12309-1082
US

IV. Provider business mailing address

47 NEW SCOTLAND AVE DEPT OF
ALBANY NY
12208-3412
US

V. Phone/Fax

Practice location:
  • Phone: 518-377-8184
  • Fax:
Mailing address:
  • Phone: 518-262-5377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number499608657
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number312201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: