Provider Demographics
NPI:1972217925
Name:GAGNON, MARY ELLEN (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GAGNON
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 1:903 BOYD ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-7513
Mailing Address - Country:US
Mailing Address - Phone:315-921-1834
Mailing Address - Fax:
Practice Address - Street 1:903 BOYD ST APT 2A
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-7513
Practice Address - Country:US
Practice Address - Phone:315-921-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311320-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY311320-01OtherNYS EDUCATION DEPT