Provider Demographics
NPI:1376628495
Name:KELDERHOUSE, JACQUELINE M (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:KELDERHOUSE
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 1:1425 WALTON AVE
Mailing Address - Street 2:MONTEFIORE SCHOOL CLINIC
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-6901
Mailing Address - Country:US
Mailing Address - Phone:718-681-8088
Mailing Address - Fax:718-537-6015
Practice Address - Street 1:1425 WALTON AVE
Practice Address - Street 2:MONTEFIORE SCHOOL CLINIC
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-6901
Practice Address - Country:US
Practice Address - Phone:718-681-8088
Practice Address - Fax:718-537-6015
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily