Provider Demographics
NPI:1629146618
Name:BRASIE, JACQUELINE L (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:L
Last Name:BRASIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5740 STATE ROUTE 13
Mailing Address - Street 2:LOT 21
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-4101
Mailing Address - Country:US
Mailing Address - Phone:315-655-2043
Mailing Address - Fax:315-655-2043
Practice Address - Street 1:5740 STATE ROUTE 13
Practice Address - Street 2:LOT 21
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-4101
Practice Address - Country:US
Practice Address - Phone:315-655-2043
Practice Address - Fax:315-655-2043
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256871-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02198103Medicaid