Provider Demographics
NPI:1356372429
Name:NISIVOCCIA, JACQUELINE MARY (DPM)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARY
Last Name:NISIVOCCIA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:77 ARROWGATE DR
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-1217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 SUNSET STRIP
Practice Address - Street 2:SUITE 306
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1345
Practice Address - Country:US
Practice Address - Phone:973-584-4600
Practice Address - Fax:973-584-9359
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00272700213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0024911Medicaid
NJU97534Medicare UPIN
NJ0024911Medicaid