Provider Demographics
NPI:1881820520
Name:JEANTY, MIKE J (LPN)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:J
Last Name:JEANTY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10113 FLATLANDS AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 RABRO DR
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4270
Practice Address - Country:US
Practice Address - Phone:631-234-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295093164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse