Provider Demographics
NPI:1710131172
Name:WHITEHEAD, MOSELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MOSELLE
Middle Name:
Last Name:WHITEHEAD
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 1:244 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3404
Mailing Address - Country:US
Mailing Address - Phone:716-831-7877
Mailing Address - Fax:716-831-8666
Practice Address - Street 1:244 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3404
Practice Address - Country:US
Practice Address - Phone:716-831-7877
Practice Address - Fax:716-831-8666
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292818-01164W00000X
NY292818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse