Provider Demographics
NPI:1164605937
Name:LAMB, PHYLLIS WANDAH (LPN)
Entity Type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:WANDAH
Last Name:LAMB
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 1:115 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-4101
Mailing Address - Country:US
Mailing Address - Phone:631-772-2253
Mailing Address - Fax:
Practice Address - Street 1:115 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-4101
Practice Address - Country:US
Practice Address - Phone:631-772-2253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272527164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02816044Medicaid