Provider Demographics
NPI:1619239878
Name:THEODAT, PATRICIA K (LPN)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:K
Last Name:THEODAT
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 1:1207 E 99TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5028
Mailing Address - Country:US
Mailing Address - Phone:347-701-0262
Mailing Address - Fax:
Practice Address - Street 1:1160 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1976
Practice Address - Country:US
Practice Address - Phone:347-701-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309961164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse