Provider Demographics
NPI:1346950060
Name:SPAGNUOLO, JACKIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:SPAGNUOLO
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 1:50 LYNBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-4509
Mailing Address - Country:US
Mailing Address - Phone:718-619-5867
Mailing Address - Fax:
Practice Address - Street 1:116 LAMBERTS LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7210
Practice Address - Country:US
Practice Address - Phone:718-619-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF31110201363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health