Provider Demographics
NPI:1104701671
Name:COLALILLO, JACQUELINE SOMMER
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SOMMER
Last Name:COLALILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 TORRINGTON LN
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-2032
Mailing Address - Country:US
Mailing Address - Phone:631-208-7094
Mailing Address - Fax:
Practice Address - Street 1:4 SMITH HAVEN MALL STE 110
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1219
Practice Address - Country:US
Practice Address - Phone:631-444-6270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant