Provider Demographics
NPI:1558819680
Name:NICOLIA, JACLYN ANNE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANNE
Last Name:NICOLIA
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 1:333 E 49TH ST
Mailing Address - Street 2:APT. 2H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-1680
Mailing Address - Country:US
Mailing Address - Phone:631-278-2599
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:845-926-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1558819680Medicaid