Provider Demographics
NPI:1477170702
Name:D'AGOSTINO, LUCILLE
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
Last Name:D'AGOSTINO
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 1:214 KING ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1142
Mailing Address - Country:US
Mailing Address - Phone:315-393-3600
Mailing Address - Fax:
Practice Address - Street 1:5 LYON PL
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2586
Practice Address - Country:US
Practice Address - Phone:315-393-2314
Practice Address - Fax:315-393-3873
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346045363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06505311Medicaid