MEDICARE: JACQUELINE CHARLENE LAMOTHE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	F381678-1	NY

General Provider Information

NPI Number	:	1336279090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CHARLENE LAMOTHE NP

Provider Business Mailing Address
First Line	:	525 E 68TH ST
Second Line	:	BOX 91
City	:	NEW YORK
State	:	NY
Zip	:	10065-4870
Country	:	US
Telephone Number	:	212-746-3278
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 EAST 68TH STREET, BOX 91
Second Line	:
City	:	NY
State	:	NY
Zip	:	10021-4870
Country	:	US
Telephone Number	:	212-746-2301
Fax Number	:	212-746-8137

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	04/24/2012

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