Provider Demographics
NPI:1063676336
Name:RICHMOND, JESSICA J (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:RICHMOND
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 1:11 REAR CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-2507
Mailing Address - Country:US
Mailing Address - Phone:845-647-3108
Mailing Address - Fax:
Practice Address - Street 1:11 REAR CHAPEL ST
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428
Practice Address - Country:US
Practice Address - Phone:845-647-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2924441164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse