Provider Demographics
NPI:1356349740
Name:BOTTICELLI, JACQUELYN ANNE (NP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:ANNE
Last Name:BOTTICELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 WALDEN AVE.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043
Mailing Address - Country:US
Mailing Address - Phone:716-668-7051
Mailing Address - Fax:716-669-7069
Practice Address - Street 1:60 INNSBRUCK DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14227-2735
Practice Address - Country:US
Practice Address - Phone:716-668-7051
Practice Address - Fax:716-669-7069
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30-304311363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9515444OtherINDEPENDENT HEALTH
NY03061112Medicaid
NY03061112Medicaid