Provider Demographics
NPI:1588977763
Name:PONTICIELLO, JACQUELINE ANN (NPP, FNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:PONTICIELLO
Suffix:
Gender:F
Credentials:NPP, FNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:BRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NPP, FNP
Mailing Address - Street 1:1901 VESTAL PKWY E STE 2W
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1966
Mailing Address - Country:US
Mailing Address - Phone:607-341-4950
Mailing Address - Fax:607-341-4933
Practice Address - Street 1:1901 VESTAL PKWY E STE 2W
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1966
Practice Address - Country:US
Practice Address - Phone:607-341-4950
Practice Address - Fax:607-341-4933
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336411363LF0000X
NY402886363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03240966Medicaid