Provider Demographics
NPI:1134437619
Name:DALTON-ZACHAREWSKI, MARY LOU (LPN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:DALTON-ZACHAREWSKI
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 1:9 WEDGEWORTH PT
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:13167-3242
Mailing Address - Country:US
Mailing Address - Phone:315-263-2397
Mailing Address - Fax:
Practice Address - Street 1:9 WEDGEWORTH PT
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:NY
Practice Address - Zip Code:13167-3242
Practice Address - Country:US
Practice Address - Phone:315-263-2397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-19
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302209-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse