Provider Demographics
NPI:1790007243
Name:INNOCENT, LEOLA
Entity Type:Individual
Prefix:
First Name:LEOLA
Middle Name:
Last Name:INNOCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-1546
Mailing Address - Country:US
Mailing Address - Phone:718-290-5218
Mailing Address - Fax:
Practice Address - Street 1:950 RUTLAND RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-1546
Practice Address - Country:US
Practice Address - Phone:718-290-5218
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
NY170539164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse