Provider Demographics
NPI:1891061263
Name:REPP, JACQUELINE (RN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:REPP
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LEHIGH STATION RD
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9620
Mailing Address - Country:US
Mailing Address - Phone:585-359-5560
Mailing Address - Fax:
Practice Address - Street 1:2000 LEHIGH STATION RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9620
Practice Address - Country:US
Practice Address - Phone:585-359-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY391557163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01497492Medicaid