Basic Information
| Provider Information | |||||||||
| NPI: | 1548633001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELL | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALIETTI | ||||||||
| OtherFirstName: | JACLYN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4271 HEMPSTEAD TPKE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117145708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167963700 | ||||||||
| FaxNumber: | 5167963205 | ||||||||
| Practice Location | |||||||||
| Address1: | 4271 HEMPSTEAD TPKE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117145708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167963700 | ||||||||
| FaxNumber: | 5167963205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 019303 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.