Provider Demographics
NPI:1154825081
Name:MIKE, SERENA KAUCHELLE (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:KAUCHELLE
Last Name:MIKE
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1054
Mailing Address - Country:US
Mailing Address - Phone:315-632-1643
Mailing Address - Fax:
Practice Address - Street 1:214 WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1054
Practice Address - Country:US
Practice Address - Phone:315-632-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325530-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse