Provider Demographics
NPI:1184391088
Name:BOGGS, JACLYN NICOLE (NP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:BOGGS
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 1:11714 197TH ST # 2
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3454
Mailing Address - Country:US
Mailing Address - Phone:772-267-0331
Mailing Address - Fax:
Practice Address - Street 1:11714 197TH ST # 2
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3454
Practice Address - Country:US
Practice Address - Phone:772-267-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703222163W00000X
NY348277363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse