Provider Demographics
NPI:1386017978
Name:BACCHUS-WAITE, JACQUELINE KATHLEEN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KATHLEEN
Last Name:BACCHUS-WAITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4817
Mailing Address - Country:US
Mailing Address - Phone:305-879-5945
Mailing Address - Fax:
Practice Address - Street 1:13 PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4817
Practice Address - Country:US
Practice Address - Phone:305-879-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343745491015R376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide