Provider Demographics
NPI:1346430618
Name:DEACON, GLORIA CARL (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:CARL
Last Name:DEACON
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 1:750 EAST 91ST STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1420
Mailing Address - Country:US
Mailing Address - Phone:718-385-1211
Mailing Address - Fax:
Practice Address - Street 1:164 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207
Practice Address - Country:US
Practice Address - Phone:347-715-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280410164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02784614Medicaid