Provider Demographics
NPI:1518563535
Name:ANDERSON, KEVONNA LYNESSA (LPN)
Entity Type:Individual
Prefix:
First Name:KEVONNA
Middle Name:LYNESSA
Last Name:ANDERSON
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 1:118 KELLER ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-3915
Mailing Address - Country:US
Mailing Address - Phone:585-736-8911
Mailing Address - Fax:
Practice Address - Street 1:118 KELLER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-3915
Practice Address - Country:US
Practice Address - Phone:585-736-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340163-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse