Provider Demographics
NPI:1922663343
Name:VEGA, ANGELICA LYNNETTE (LPN)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:LYNNETTE
Last Name:VEGA
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 1:146 STATE ROUTE 104 APT 4E
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-8944
Mailing Address - Country:US
Mailing Address - Phone:607-346-3361
Mailing Address - Fax:
Practice Address - Street 1:146 STATE ROUTE 104 APT 4E
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-8944
Practice Address - Country:US
Practice Address - Phone:607-346-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332999164W00000X
NY33299164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse