Provider Demographics
NPI:1073260402
Name:SPRAGUE, LANDYN RAE
Entity Type:Individual
Prefix:
First Name:LANDYN
Middle Name:RAE
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 FAIRPORT NINE MILE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1903
Mailing Address - Country:US
Mailing Address - Phone:585-758-0777
Mailing Address - Fax:
Practice Address - Street 1:1835 FAIRPORT NINE MILE POINT RD
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1903
Practice Address - Country:US
Practice Address - Phone:585-758-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner