Provider Demographics
NPI:1992841696
Name:DANDRIDGE, JACQUELINE R (LPN LICENSE)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:R
Last Name:DANDRIDGE
Suffix:
Gender:F
Credentials:LPN LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HEANEY DR
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-4113
Mailing Address - Country:US
Mailing Address - Phone:845-831-6196
Mailing Address - Fax:845-831-6196
Practice Address - Street 1:29 WENDY DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6017
Practice Address - Country:US
Practice Address - Phone:845-298-2176
Practice Address - Fax:845-298-2176
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2498221164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01805834Medicaid