Provider Demographics
NPI:1902033772
Name:ROONEY-UDICIOUS, JACQUELINE ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNE
Last Name:ROONEY-UDICIOUS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-590-1000
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BOULEVARD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009936363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN565963OtherPA. RN LICENSE
PA10225936440001Medicaid
PASP009936OtherPA CERTIFIED NURSE PRACTITIONER LICENSE
PA10225936440001Medicaid