Basic Information
| Provider Information | |||||||||
| NPI: | 1154865335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLITO | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER STREET | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 1991 MARCUS AVE, 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110422057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163541600 | ||||||||
| FaxNumber: | 5169414677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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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 | 363LA2200X | 308016 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.