Provider Demographics
NPI:1326700972
Name:ROMAN, JACQUELINE (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROMAN
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 1:575 UNDERHILL BLVD STE 190
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3494
Mailing Address - Country:US
Mailing Address - Phone:516-364-9800
Mailing Address - Fax:516-364-9802
Practice Address - Street 1:136 CRANBERRY CT
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-8722
Practice Address - Country:US
Practice Address - Phone:631-470-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310462-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health