Provider Demographics
NPI:1225688989
Name:PRUDENT, GLADYS
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:PRUDENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 AMERICA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-4032
Mailing Address - Country:US
Mailing Address - Phone:516-417-3796
Mailing Address - Fax:
Practice Address - Street 1:1291 AMERICA AVE
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-4032
Practice Address - Country:US
Practice Address - Phone:516-417-3796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229413-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse