Basic Information
| Provider Information | |||||||||
| NPI: | 1043476237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUCCINELLO | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | ROSEANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5225 RTE 347 STE 70 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117762061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313318777 | ||||||||
| FaxNumber: | 6314749169 | ||||||||
| Practice Location | |||||||||
| Address1: | 5225 RTE 347 STE 70 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117762061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313318777 | ||||||||
| FaxNumber: | 6314749169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 565107 | NY | N | Nursing Service Providers | Registered Nurse | 363LW0102X | F421258-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 565107 | 05 | NY | MEDICAID |