Provider Demographics
NPI:1659615409
Name:PILGRAM, KEONE (LPN)
Entity Type:Individual
Prefix:MR
First Name:KEONE
Middle Name:
Last Name:PILGRAM
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 DARTMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1006
Mailing Address - Country:US
Mailing Address - Phone:716-603-7758
Mailing Address - Fax:
Practice Address - Street 1:102 DARTMOUTH AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1006
Practice Address - Country:US
Practice Address - Phone:716-603-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-18
Last Update Date:2012-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3019311164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse