Provider Demographics
NPI:1417960683
Name:POMPONIO, JACKY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JACKY
Middle Name:
Last Name:POMPONIO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E HILLSBORO BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-4355
Mailing Address - Country:US
Mailing Address - Phone:954-428-1771
Mailing Address - Fax:954-422-9538
Practice Address - Street 1:1500 E HILLSBORO BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-4355
Practice Address - Country:US
Practice Address - Phone:954-428-1771
Practice Address - Fax:954-422-9538
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP749662363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS92691Medicare UPIN
FLE3273ZMedicare ID - Type UnspecifiedMEDICARE NUMBER