Provider Demographics
NPI:1023095098
Name:KACZMAREK, JILL (NP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4888
Mailing Address - Country:US
Mailing Address - Phone:716-668-5331
Mailing Address - Fax:716-668-5370
Practice Address - Street 1:4711 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14043-4888
Practice Address - Country:US
Practice Address - Phone:716-668-5331
Practice Address - Fax:716-668-5370
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333250363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560626003OtherBC/BS
NY9511960OtherIHA
NY00026518302OtherUNIVERA
NY02343424Medicaid