Provider Demographics
NPI:1912122136
Name:KIELTY, JACQUELINE ALLISON (PA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ALLISON
Last Name:KIELTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 COCKS LN
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-2313
Mailing Address - Country:US
Mailing Address - Phone:516-801-2571
Mailing Address - Fax:
Practice Address - Street 1:104 FOREST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2015
Practice Address - Country:US
Practice Address - Phone:516-759-5406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011007363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical