Provider Demographics
NPI:1316111859
Name:PITT, JACQUELINE MAXCINE (RN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MAXCINE
Last Name:PITT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1318
Mailing Address - Country:US
Mailing Address - Phone:516-379-7689
Mailing Address - Fax:516-379-7689
Practice Address - Street 1:133 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1318
Practice Address - Country:US
Practice Address - Phone:516-379-7689
Practice Address - Fax:516-379-7689
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY447495163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02759768Medicaid