Provider Demographics
NPI:1326502105
Name:MOSS, BEANCA SADA (LPN)
Entity Type:Individual
Prefix:
First Name:BEANCA
Middle Name:SADA
Last Name:MOSS
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 1:128 W PLEASANT ST APT O2
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1716
Mailing Address - Country:US
Mailing Address - Phone:315-427-7543
Mailing Address - Fax:
Practice Address - Street 1:128 W PLEASANT ST APT O2
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-1716
Practice Address - Country:US
Practice Address - Phone:315-427-7543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328809-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse