Provider Demographics
NPI:1942764667
Name:PRINCE, LORAIN L
Entity Type:Individual
Prefix:MRS
First Name:LORAIN
Middle Name:L
Last Name:PRINCE
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 1:263 BLUE POINT AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1224
Mailing Address - Country:US
Mailing Address - Phone:631-977-1235
Mailing Address - Fax:
Practice Address - Street 1:9 ADAMS RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2201
Practice Address - Country:US
Practice Address - Phone:631-374-0967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330866164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse