Provider Demographics
NPI: | 1205378668 |
---|---|
Name: | MARGOLESE, JACQUELINE (MSN, FNP-C, AG-ACNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | JACQUELINE |
Middle Name: | |
Last Name: | MARGOLESE |
Suffix: | |
Gender: | F |
Credentials: | MSN, FNP-C, AG-ACNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 20103 LAKE CHABOT RD |
Mailing Address - Street 2: | |
Mailing Address - City: | CASTRO VALLEY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94546-5305 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 510-727-2759 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 20103 LAKE CHABOT RD |
Practice Address - Street 2: | |
Practice Address - City: | CASTRO VALLEY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94546-5305 |
Practice Address - Country: | US |
Practice Address - Phone: | 510-727-2759 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-11-15 |
Last Update Date: | 2018-10-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 95008327 | 363L00000X |
HI | APRN-2206 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
0 | Other | N/A |