Provider Demographics
NPI:1548598543
Name:FISH, THERESA LOUISE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LOUISE
Last Name:FISH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:LOUISE
Other - Last Name:ALLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6580 ROUND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAVONA
Mailing Address - State:NY
Mailing Address - Zip Code:14879-9717
Mailing Address - Country:US
Mailing Address - Phone:607-583-4101
Mailing Address - Fax:
Practice Address - Street 1:6580 ROUND LAKE RD
Practice Address - Street 2:
Practice Address - City:SAVONA
Practice Address - State:NY
Practice Address - Zip Code:14879-9717
Practice Address - Country:US
Practice Address - Phone:607-583-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223596-1164W00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist