Provider Demographics
NPI:1013121185
Name:KIRKLAND, MARK RAYMOND (LPN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RAYMOND
Last Name:KIRKLAND
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11108 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14062-9719
Mailing Address - Country:US
Mailing Address - Phone:716-965-4338
Mailing Address - Fax:
Practice Address - Street 1:6855 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:NY
Practice Address - Zip Code:14085-9642
Practice Address - Country:US
Practice Address - Phone:716-627-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272466-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02832864Medicaid