Provider Demographics
NPI:1013342849
Name:RIDLEY, TREVORLYN A (LPN)
Entity Type:Individual
Prefix:MS
First Name:TREVORLYN
Middle Name:A
Last Name:RIDLEY
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 1:17 RUTH ELLEN WAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3507
Mailing Address - Country:US
Mailing Address - Phone:585-764-8266
Mailing Address - Fax:
Practice Address - Street 1:17 RUTH ELLEN WAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3507
Practice Address - Country:US
Practice Address - Phone:585-764-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse