Provider Demographics
NPI:1093287906
Name:HILL, LETA
Entity Type:Individual
Prefix:
First Name:LETA
Middle Name:
Last Name:HILL
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 1:1095 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-2414
Mailing Address - Country:US
Mailing Address - Phone:716-816-4180
Mailing Address - Fax:
Practice Address - Street 1:1095 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-2414
Practice Address - Country:US
Practice Address - Phone:716-816-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9439380164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9439380Medicaid