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General NPI Number Information
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NPI Number | 1679897060
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Entity Type | Individual
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Provider Name | JACQUELINE MARJORIE LICHTENSTEIN PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/15/2010
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Last Update Date | 10/04/2024
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Provider Practice Location Address
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Address Line | 340 HOWELLS RD STE 2B
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City | BAY SHORE
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State | NY
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Zip | 11706-5322
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Country | US
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Telephone | 833-547-7463
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Fax | 631-318-9830
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Provider Business Mailing Address
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Address Line | 100 MOTOR PARKWAY SUITE LL8
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City | HAUPPAUGE
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State | NY
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Zip | 11788
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Country | US
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Telephone | 833-547-7463
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Fax | 631-248-5583
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 019016
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License Number State | NY
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