Provider Demographics
NPI:1114185790
Name:PEALO, LINDA DIANA (LPN)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:DIANA
Last Name:PEALO
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 1:77 WILSONIA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-6719
Mailing Address - Country:US
Mailing Address - Phone:585-482-2420
Mailing Address - Fax:
Practice Address - Street 1:77 WILSONIA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-6719
Practice Address - Country:US
Practice Address - Phone:585-482-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278813-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02732438Medicaid