Provider Demographics
NPI:1033745203
Name:BRISTOW, DECARRA D (LPN)
Entity Type:Individual
Prefix:
First Name:DECARRA
Middle Name:D
Last Name:BRISTOW
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 1:3896 DEWEY AVE # 142
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-2527
Mailing Address - Country:US
Mailing Address - Phone:585-736-0585
Mailing Address - Fax:
Practice Address - Street 1:3896 DEWEY AVE # 142
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-2527
Practice Address - Country:US
Practice Address - Phone:585-736-0585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337747164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse