Provider Demographics
NPI:1053734889
Name:D'ELETTO, JACQUELINE DENISE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENISE
Last Name:D'ELETTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:SPALLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-442-5320
Mailing Address - Fax:585-442-5526
Practice Address - Street 1:1415 PORTLAND AVE STE 350
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3043
Practice Address - Country:US
Practice Address - Phone:585-442-5320
Practice Address - Fax:585-442-5526
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017338363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400135260/70008AMedicare PIN
NYJ400135261/GP BA0017Medicare PIN