Provider Demographics
NPI:1225197866
Name:PANDOLFI, JACQUELINE (NP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:PANDOLFI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MERCHANTS CONCOURSE STE 216
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5114
Mailing Address - Country:US
Mailing Address - Phone:516-226-8373
Mailing Address - Fax:844-632-8265
Practice Address - Street 1:12 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1588
Practice Address - Country:US
Practice Address - Phone:631-331-4400
Practice Address - Fax:631-331-3190
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY388956-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY388956Medicaid
NY388956Medicaid