Provider Demographics
NPI:1043773377
Name:CLANCY, MELINDA LATOYA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MELINDA
Middle Name:LATOYA
Last Name:CLANCY
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 1:492 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1904
Mailing Address - Country:US
Mailing Address - Phone:585-287-7055
Mailing Address - Fax:
Practice Address - Street 1:492 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1904
Practice Address - Country:US
Practice Address - Phone:585-287-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296159-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse