Provider Demographics
NPI:1467669192
Name:MOSLEY, ERNEST TAYLOR JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:TAYLOR
Last Name:MOSLEY
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-3113
Mailing Address - Country:US
Mailing Address - Phone:631-772-6702
Mailing Address - Fax:
Practice Address - Street 1:118 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-3113
Practice Address - Country:US
Practice Address - Phone:631-772-6702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00254892164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01801734Medicaid