Provider Demographics
NPI:1508182908
Name:BENTLEY, MYA NADINE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MYA
Middle Name:NADINE
Last Name:BENTLEY
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 1:1136 VINE ST.
Mailing Address - Street 2:D-12
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-372-2672
Mailing Address - Fax:
Practice Address - Street 1:1136 VINE ST
Practice Address - Street 2:D-12
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-372-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299270164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse