Provider Demographics
NPI:1083350524
Name:TRIVISON, AMY SUE (LPN LICENSE # 275747)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:TRIVISON
Suffix:
Gender:F
Credentials:LPN LICENSE # 275747
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:SAVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN LICENSE # 275747
Mailing Address - Street 1:302 CHARLANE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4211
Mailing Address - Country:US
Mailing Address - Phone:315-402-4518
Mailing Address - Fax:
Practice Address - Street 1:302 CHARLANE PARKWAY
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4211
Practice Address - Country:US
Practice Address - Phone:315-402-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275747164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07762027Medicaid