Provider Demographics
NPI:1275095861
Name:MCCLARY, TATANISHA MONIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:TATANISHA
Middle Name:MONIQUE
Last Name:MCCLARY
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 1:57 ARBUTUS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-3501
Mailing Address - Country:US
Mailing Address - Phone:585-201-4007
Mailing Address - Fax:
Practice Address - Street 1:57 ARBUTUS ST APT 2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-3501
Practice Address - Country:US
Practice Address - Phone:585-201-4007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331855-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse