Provider Demographics
NPI:1316592983
Name:PANTRY, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:PANTRY
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 1:13624 241ST ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1520
Mailing Address - Country:US
Mailing Address - Phone:646-872-7094
Mailing Address - Fax:
Practice Address - Street 1:13624 241ST ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1520
Practice Address - Country:US
Practice Address - Phone:646-872-7094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264882-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse