Provider Demographics
NPI:1548392624
Name:BUSH, GAIL K (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:K
Last Name:BUSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:JOAN
Other - Last Name:KUNKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:315-946-7005
Practice Address - Street 1:1519 NYE ROAD
Practice Address - Street 2:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0809481164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249154Medicaid