Provider Demographics
NPI:1710243613
Name:DWYER, LEISA KAY (RN)
Entity Type:Individual
Prefix:MS
First Name:LEISA
Middle Name:KAY
Last Name:DWYER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 847
Mailing Address - Street 2:42 HUSKIE LANE
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953
Mailing Address - Country:US
Mailing Address - Phone:518-483-7800
Mailing Address - Fax:518-483-3071
Practice Address - Street 1:183 WEBSTER STREET
Practice Address - Street 2:DAVIS ELEMENTARY
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-7802
Practice Address - Fax:518-483-6390
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY493695-1(RNLICENSE)163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool