Provider Demographics
NPI:1508344664
Name:WILSONBERGLAS, MARYJENNIFER (LPN)
Entity Type:Individual
Prefix:
First Name:MARYJENNIFER
Middle Name:
Last Name:WILSONBERGLAS
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 1:15 FORTUNE RD W
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1625
Mailing Address - Country:US
Mailing Address - Phone:845-421-6463
Mailing Address - Fax:845-343-8396
Practice Address - Street 1:15 FORTUNE RD W
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1625
Practice Address - Country:US
Practice Address - Phone:845-421-6463
Practice Address - Fax:845-343-8396
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206069164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse