Provider Demographics
NPI:1336279090
Name:LAMOTHE, JACQUELINE CHARLENE (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CHARLENE
Last Name:LAMOTHE
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 1:525 E 68TH ST
Mailing Address - Street 2:BOX 91
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-3278
Mailing Address - Fax:
Practice Address - Street 1:525 EAST 68TH STREET, BOX 91
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10021-4870
Practice Address - Country:US
Practice Address - Phone:212-746-2301
Practice Address - Fax:212-746-8137
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381678-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics