Provider Demographics
NPI:1205011061
Name:OBIANYOR, JACKIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:
Last Name:OBIANYOR
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 1:485 FRONT ST
Mailing Address - Street 2:#107
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4416
Mailing Address - Country:US
Mailing Address - Phone:516-214-4461
Mailing Address - Fax:
Practice Address - Street 1:485 FRONT ST
Practice Address - Street 2:#107
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4416
Practice Address - Country:US
Practice Address - Phone:516-214-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246360-1164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02151577Medicaid