Provider Demographics
NPI:1043431588
Name:FANELLE, JACQUALYN S (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JACQUALYN
Middle Name:S
Last Name:FANELLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JACQUALYN
Other - Middle Name:M
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:866-709-4546
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6912
Practice Address - Country:US
Practice Address - Phone:856-641-7859
Practice Address - Fax:856-641-7671
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR07270700163W00000X
NJ26NJ00207600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
39668OtherAANA
NJP00795657OtherRAILROAD MEDICARE
NJP00795657OtherRAILROAD MEDICARE