Provider Demographics
NPI:1619910718
Name:TELAAK, JUNE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:MARIE
Last Name:TELAAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1344 MCKINLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1643
Mailing Address - Country:US
Mailing Address - Phone:716-649-0887
Mailing Address - Fax:716-646-4611
Practice Address - Street 1:15 MELROY AVE
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1626
Practice Address - Country:US
Practice Address - Phone:716-549-4724
Practice Address - Fax:716-821-0568
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331367363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026501304OtherUNIVERA
NY000560258006OtherBLUE CROSS BLUE SHIELD
NY02074257Medicaid
9511891OtherIHA
NY02074257Medicaid
NY000560258006OtherBLUE CROSS BLUE SHIELD