Provider Demographics
NPI:1669144762
Name:JAMELO, MA FIDES (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MA FIDES
Middle Name:
Last Name:JAMELO
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:JAMELO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:PO BOX 3504
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-8504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF432131-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty