Provider Demographics
NPI:1992905582
Name:POLTORACK, JAYNE ELIZABETH (RN)
Entity type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:ELIZABETH
Last Name:POLTORACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:479 ROUTE 17K
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12721-3206
Mailing Address - Country:US
Mailing Address - Phone:845-325-9928
Mailing Address - Fax:
Practice Address - Street 1:5900 ARLINGTON AVE
Practice Address - Street 2:APARTMENT 22J
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1302
Practice Address - Country:US
Practice Address - Phone:914-390-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280977-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729688Medicaid