Provider Demographics
NPI:1609890516
Name:MCDERMOTT, LUCILLE DIANA
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:DIANA
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-1920
Mailing Address - Country:US
Mailing Address - Phone:315-822-3200
Mailing Address - Fax:315-822-5193
Practice Address - Street 1:943 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:WEST WINFIELD
Practice Address - State:NY
Practice Address - Zip Code:13491-1920
Practice Address - Country:US
Practice Address - Phone:315-822-3200
Practice Address - Fax:315-822-5193
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02648180Medicaid
NYRA6735Medicare ID - Type Unspecified
NYQ44001Medicare UPIN