Provider Demographics
NPI:1851014609
Name:LANGE, JOELLA
Entity Type:Individual
Prefix:
First Name:JOELLA
Middle Name:
Last Name:LANGE
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 1:5048 GAYLORD RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:14590-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5048 GAYLORD RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590-9305
Practice Address - Country:US
Practice Address - Phone:585-642-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751145-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse