Provider Demographics
NPI:1497138119
Name:IYASERE, MILDRED
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:IYASERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MILDRED
Other - Middle Name:
Other - Last Name:ESENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:1015 DELAWARE AVE
Mailing Address - Street 2:404
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1651
Mailing Address - Country:US
Mailing Address - Phone:716-361-3095
Mailing Address - Fax:
Practice Address - Street 1:69 DELAWARE AVE
Practice Address - Street 2:1200
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-3812
Practice Address - Country:US
Practice Address - Phone:716-852-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3166681164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse