Provider Demographics
NPI:1811218340
Name:DETTELIS, KAREN M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:M
Last Name:DETTELIS
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 1:23 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:DELEVAN
Mailing Address - State:NY
Mailing Address - Zip Code:14042-9661
Mailing Address - Country:US
Mailing Address - Phone:716-353-1087
Mailing Address - Fax:
Practice Address - Street 1:23 SMITH AVE
Practice Address - Street 2:
Practice Address - City:DELEVAN
Practice Address - State:NY
Practice Address - Zip Code:14042-9661
Practice Address - Country:US
Practice Address - Phone:716-353-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1965581164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse