Provider Demographics
NPI:1346586609
Name:TRUDEAU, MICHAELA LOYOLA
Entity Type:Individual
Prefix:
First Name:MICHAELA LOYOLA
Middle Name:
Last Name:TRUDEAU
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 1:3402 STATE ROUTE 196
Mailing Address - Street 2:
Mailing Address - City:FORT ANN
Mailing Address - State:NY
Mailing Address - Zip Code:12827-3706
Mailing Address - Country:US
Mailing Address - Phone:518-744-2047
Mailing Address - Fax:
Practice Address - Street 1:3402 STATE ROUTE 196
Practice Address - Street 2:
Practice Address - City:FORT ANN
Practice Address - State:NY
Practice Address - Zip Code:12827-3706
Practice Address - Country:US
Practice Address - Phone:518-744-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311791164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03534549Medicaid