Provider Demographics
NPI:1346579166
Name:PANDOLFO, JACQUELINE (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PANDOLFO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269-01 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:718-470-3611
Mailing Address - Fax:718-343-2961
Practice Address - Street 1:269-01 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:718-470-3611
Practice Address - Fax:718-343-2961
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336097-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily