Provider Demographics
NPI:1831860923
Name:JAQUAY, AMANDA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JAQUAY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 E SPOFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:DOLGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13329-1478
Mailing Address - Country:US
Mailing Address - Phone:315-717-1875
Mailing Address - Fax:
Practice Address - Street 1:111 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2541
Practice Address - Country:US
Practice Address - Phone:315-895-7471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY716108163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool