Provider Demographics
NPI:1336513142
Name:DRAKE, DEBORAH (CASAC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-952-8408
Mailing Address - Fax:
Practice Address - Street 1:80 SHARRON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-4700
Practice Address - Country:US
Practice Address - Phone:518-561-1447
Practice Address - Fax:518-562-8812
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093497164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid