Provider Demographics
NPI:1255914263
Name:JOSEPH, DEDRA D (LPN)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:D
Last Name:JOSEPH
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 1:62 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2322
Mailing Address - Country:US
Mailing Address - Phone:516-412-1240
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE FL 2
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6223
Practice Address - Country:US
Practice Address - Phone:516-204-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280219-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse