Provider Demographics
NPI:1033593777
Name:CARDONA, JULLISSA AMANDA (LPN)
Entity Type:Individual
Prefix:
First Name:JULLISSA
Middle Name:AMANDA
Last Name:CARDONA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MEIER PL
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4320
Mailing Address - Country:US
Mailing Address - Phone:631-649-5529
Mailing Address - Fax:
Practice Address - Street 1:34 MEIER PL
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4320
Practice Address - Country:US
Practice Address - Phone:631-649-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322240-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse