Provider Demographics
NPI:1487008900
Name:COREIA, JACQUELYN S
Entity Type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:S
Last Name:COREIA
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 1:2273 W GENESEE RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027
Mailing Address - Country:US
Mailing Address - Phone:315-572-5520
Mailing Address - Fax:
Practice Address - Street 1:2273 W GENESEE RD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-9674
Practice Address - Country:US
Practice Address - Phone:315-572-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235781-1372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY235781-1OtherLPN LICENSE