Provider Demographics
NPI:1821648395
Name:BERTCH, LESANDRA JUNE (RN)
Entity Type:Individual
Prefix:
First Name:LESANDRA
Middle Name:JUNE
Last Name:BERTCH
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 1:1126 BALD HILL RD
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1262
Mailing Address - Country:US
Mailing Address - Phone:607-281-3177
Mailing Address - Fax:607-324-3842
Practice Address - Street 1:1126 BALD HILL RD
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-1262
Practice Address - Country:US
Practice Address - Phone:607-281-3177
Practice Address - Fax:607-324-3842
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY378567-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000000Medicaid