Provider Demographics
NPI:1033438833
Name:O'CONNOR, MALISSA ELIZABETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MALISSA
Middle Name:ELIZABETH
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:ELIZABETH
Other - Last Name:BLOODGOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4519 SOUTH SALINA STREET
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205
Mailing Address - Country:US
Mailing Address - Phone:315-469-3823
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-453-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285211-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse