Provider Demographics
NPI:1154081925
Name:QUACKENBUSH, AMY LEE (LPN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:QUACKENBUSH
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 1:73 N MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-3043
Mailing Address - Country:US
Mailing Address - Phone:518-319-7978
Mailing Address - Fax:518-514-1521
Practice Address - Street 1:73 N MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-3043
Practice Address - Country:US
Practice Address - Phone:518-319-7978
Practice Address - Fax:518-514-1521
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329563164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse