Provider Demographics
NPI:1811017312
Name:SMITH, PATRICIA J (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13411-4730
Mailing Address - Country:US
Mailing Address - Phone:607-847-9720
Mailing Address - Fax:
Practice Address - Street 1:106 GROVE AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:NY
Practice Address - Zip Code:13411-4730
Practice Address - Country:US
Practice Address - Phone:607-847-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261671-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02053827Medicaid