Provider Demographics
NPI:1891017620
Name:MIKE, VONNIE M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:VONNIE
Middle Name:M
Last Name:MIKE
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 1:245 MOORE AVE
Mailing Address - Street 2:1-1B
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-3549
Mailing Address - Country:US
Mailing Address - Phone:315-471-6549
Mailing Address - Fax:
Practice Address - Street 1:2105 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1698
Practice Address - Country:US
Practice Address - Phone:315-468-3239
Practice Address - Fax:315-468-2917
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY079591-1OtherLPN LICENSE