=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912122136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE ALLISON KIELTY P.A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 FOREST AVE
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-759-5406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 COCKS LN
-----------------------------------------------------
City | LOCUST VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11560-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-801-2571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 011007
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------