Provider Demographics
NPI:1760776199
Name:ROYALTY, JACLYN LEE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:LEE
Last Name:ROYALTY
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 1:8128 NATURES WAY UNIT 13
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-4124
Mailing Address - Country:US
Mailing Address - Phone:815-343-7064
Mailing Address - Fax:
Practice Address - Street 1:1261 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2219
Practice Address - Country:US
Practice Address - Phone:941-366-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9260993367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered