Provider Demographics
NPI:1437658051
Name:EDIE-PROVOST, HOPE (LPN)
Entity Type:Individual
Prefix:
First Name:HOPE
Middle Name:
Last Name:EDIE-PROVOST
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 1:23 C V WAY
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3371
Mailing Address - Country:US
Mailing Address - Phone:518-572-9094
Mailing Address - Fax:
Practice Address - Street 1:20 HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2541
Practice Address - Country:US
Practice Address - Phone:518-563-2439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329469164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse