Provider Demographics
NPI:1336370030
Name:BLISS, SALLY (LPN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BLISS
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 1:3294 ROUTE 394
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NY
Mailing Address - Zip Code:14772-9708
Mailing Address - Country:US
Mailing Address - Phone:716-358-2503
Mailing Address - Fax:
Practice Address - Street 1:1680 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4914
Practice Address - Country:US
Practice Address - Phone:716-894-7777
Practice Address - Fax:716-894-0604
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258112-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse