Provider Demographics
NPI:1285854828
Name:PERDUE-DORATHY, JACQUELINE SUE (LPN)
Entity Type:Individual
Prefix:MR
First Name:JACQUELINE
Middle Name:SUE
Last Name:PERDUE-DORATHY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:SUE
Other - Last Name:PERDUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:19445 COUNTRYSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MO
Mailing Address - Zip Code:64098-9127
Mailing Address - Country:US
Mailing Address - Phone:913-684-6170
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-681-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23-27018-081164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse