Provider Demographics
NPI:1043499189
Name:DALE, HEATHER H (LPN)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:H
Last Name:DALE
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 1:15 BRITTANY CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768
Mailing Address - Country:US
Mailing Address - Phone:631-889-0211
Mailing Address - Fax:
Practice Address - Street 1:15 BRITTANY CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768
Practice Address - Country:US
Practice Address - Phone:631-889-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2438521164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01629941Medicaid