Provider Demographics
NPI:1679057939
Name:O'CONNOR, LORETTA JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:JEAN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:JEAN
Other - Last Name:MCCARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-788-7430
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:1704 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3102
Practice Address - Country:US
Practice Address - Phone:315-788-7430
Practice Address - Fax:315-785-5637
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257735-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3372621Medicaid