Provider Demographics
NPI:1861101818
Name:TAVERNIER, JAMIE (RN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:TAVERNIER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:75 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATEAUGAY
Mailing Address - State:NY
Mailing Address - Zip Code:12920-2900
Mailing Address - Country:US
Mailing Address - Phone:518-651-4822
Mailing Address - Fax:
Practice Address - Street 1:31 6TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1246
Practice Address - Country:US
Practice Address - Phone:518-651-4822
Practice Address - Fax:518-483-3383
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554156-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY554156-01OtherREGISTERED NURSE LICENSE
VT026.0146584OtherREGISTERED NURSE LICENSE