Provider Demographics
NPI:1750506317
Name:VYVERBERG, LORRAINE (RN)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:VYVERBERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CHASE ROAD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468
Mailing Address - Country:US
Mailing Address - Phone:585-392-9520
Mailing Address - Fax:
Practice Address - Street 1:112 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:ROCH
Practice Address - State:NY
Practice Address - Zip Code:14616
Practice Address - Country:US
Practice Address - Phone:585-503-8119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4582931163W00000X
NYF333027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01637865Medicaid