Provider Demographics
NPI:1043476237
Name:CUCCINELLO, JACLYN ROSEANN (NP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROSEANN
Last Name:CUCCINELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 RTE 347 STE 70
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2061
Mailing Address - Country:US
Mailing Address - Phone:631-331-8777
Mailing Address - Fax:631-474-9169
Practice Address - Street 1:5225 RTE 347 STE 70
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2061
Practice Address - Country:US
Practice Address - Phone:631-331-8777
Practice Address - Fax:631-474-9169
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY565107163W00000X
NYF421258-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY565107Medicaid