Provider Demographics
NPI:1750678165
Name:MCCANTS, ILLONDA CHEREESE
Entity Type:Individual
Prefix:MRS
First Name:ILLONDA
Middle Name:CHEREESE
Last Name:MCCANTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ILLONDA
Other - Middle Name:CHEREESE
Other - Last Name:MCCANTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:338 BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-4825
Mailing Address - Country:US
Mailing Address - Phone:347-543-0291
Mailing Address - Fax:585-266-7733
Practice Address - Street 1:338 BERNARD ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4825
Practice Address - Country:US
Practice Address - Phone:347-543-0291
Practice Address - Fax:585-266-7733
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY710581163WG0000X
NY10276448164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice