Provider Demographics
NPI:1184150153
Name:MOUDRIK, JANE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:MOUDRIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:KAUNEONGA LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12749-0454
Mailing Address - Country:US
Mailing Address - Phone:845-807-8818
Mailing Address - Fax:
Practice Address - Street 1:44 HENREY STREET WURTSBORO
Practice Address - Street 2:
Practice Address - City:KAUNEONGA LAKE
Practice Address - State:NY
Practice Address - Zip Code:12749-0454
Practice Address - Country:US
Practice Address - Phone:845-807-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse