Provider Demographics
NPI:1164980496
Name:GLAVES, LORRAINE JANICE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:JANICE
Last Name:GLAVES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:CROTON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10520-0201
Mailing Address - Country:US
Mailing Address - Phone:914-739-2587
Mailing Address - Fax:914-739-2587
Practice Address - Street 1:2308 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3494
Practice Address - Country:US
Practice Address - Phone:718-224-9094
Practice Address - Fax:718-313-0436
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235075-4207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine