Provider Demographics
NPI:1497982367
Name:DWYER, JESSIE JAMES (LPN)
Entity Type:Individual
Prefix:MISS
First Name:JESSIE
Middle Name:JAMES
Last Name:DWYER
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 1:1120 MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:NY
Mailing Address - Zip Code:13112-8717
Mailing Address - Country:US
Mailing Address - Phone:315-708-2291
Mailing Address - Fax:
Practice Address - Street 1:1120 MORGAN RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:NY
Practice Address - Zip Code:13112-8717
Practice Address - Country:US
Practice Address - Phone:315-708-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294649-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse