Provider Demographics
NPI:1245566934
Name:GILLETTE, MARY MAY (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAY
Last Name:GILLETTE
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 1:81 S GLENORA RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:NY
Mailing Address - Zip Code:14837-8842
Mailing Address - Country:US
Mailing Address - Phone:607-243-8714
Mailing Address - Fax:
Practice Address - Street 1:81 S GLENORA RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:NY
Practice Address - Zip Code:14837-8842
Practice Address - Country:US
Practice Address - Phone:607-243-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2568451164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02786038Medicaid