Provider Demographics
NPI:1699019455
Name:CULLINANE, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CULLINANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:CONCEPCION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100111
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3111
Mailing Address - Country:US
Mailing Address - Phone:845-596-6394
Mailing Address - Fax:
Practice Address - Street 1:4800 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6004
Practice Address - Country:US
Practice Address - Phone:904-483-5850
Practice Address - Fax:904-483-5860
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY532232-1163W00000X
NJ26NR14781900163W00000X
FLAPRN11014964367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111966800Medicaid