Provider Demographics
NPI:1154865335
Name:POLITO, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:POLITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1991 MARCUS AVE, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2057
Practice Address - Country:US
Practice Address - Phone:516-354-1600
Practice Address - Fax:516-941-4677
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308016363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health