Provider Demographics
NPI:1881863181
Name:STAFFORD, COLLEEN MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5897 STATE RT. 281
Mailing Address - Street 2:
Mailing Address - City:LITTLE YORK
Mailing Address - State:NY
Mailing Address - Zip Code:13077
Mailing Address - Country:US
Mailing Address - Phone:607-423-6465
Mailing Address - Fax:
Practice Address - Street 1:5897 RT 281
Practice Address - Street 2:
Practice Address - City:LITTLE YORK
Practice Address - State:NY
Practice Address - Zip Code:13087
Practice Address - Country:US
Practice Address - Phone:607-423-6465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1207621164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933848Medicaid