Provider Demographics
NPI:1710209267
Name:SMALL, DAVE (LPN)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:SMALL
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 1:664 E 77TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3316
Mailing Address - Country:US
Mailing Address - Phone:954-806-1140
Mailing Address - Fax:
Practice Address - Street 1:664 E 77TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3316
Practice Address - Country:US
Practice Address - Phone:954-806-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284092164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY284092OtherLPN LICENSE