Provider Demographics
NPI:1184966053
Name:LIDDLE, ANTHONY GARRICK (LPN)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:GARRICK
Last Name:LIDDLE
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 1:31 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-1079
Mailing Address - Country:US
Mailing Address - Phone:631-369-3179
Mailing Address - Fax:
Practice Address - Street 1:31 CENTER DR
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1079
Practice Address - Country:US
Practice Address - Phone:631-369-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311434164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse