Provider Demographics
NPI:1346780046
Name:NICOLICH, JACQUELINE CHANTAL (RPA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CHANTAL
Last Name:NICOLICH
Suffix:
Gender:
Credentials:RPA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:CHANTAL
Other - Last Name:ROSANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:4 SPRINGVILLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2290
Mailing Address - Country:US
Mailing Address - Phone:631-726-8717
Mailing Address - Fax:631-726-8720
Practice Address - Street 1:MEETING HOUSE LANE MEDICAL PRACTICE, PC SURGICAL SPEC.
Practice Address - Street 2:240
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-726-8717
Practice Address - Fax:631-726-8720
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020637363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical