Provider Demographics
NPI:1255668927
Name:SCULLY, JENNY REBECCA (LPN)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:REBECCA
Last Name:SCULLY
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 1:24 OLIVETTI PL
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2613
Mailing Address - Country:US
Mailing Address - Phone:518-310-1316
Mailing Address - Fax:
Practice Address - Street 1:24 OLIVETTI PL
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2613
Practice Address - Country:US
Practice Address - Phone:518-310-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274539-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse