1346780046 NPI number — JACQUELINE CHANTAL NICOLICH RPA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346780046 NPI number — JACQUELINE CHANTAL NICOLICH RPA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICOLICH
Provider First Name:
JACQUELINE
Provider Middle Name:
CHANTAL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSANTE
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
CHANTAL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346780046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 SPRINGVILLE RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON BAYS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11946-2290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-726-8717
Provider Business Mailing Address Fax Number:
631-726-8720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MEETING HOUSE LANE MEDICAL PRACTICE, PC SURGICAL SPEC.
Provider Second Line Business Practice Location Address:
240
Provider Business Practice Location Address City Name:
SOUTHAMPTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-726-8717
Provider Business Practice Location Address Fax Number:
631-726-8720
Provider Enumeration Date:
02/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  020637 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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