Provider Demographics
NPI:1477994143
Name:POBLANO, LUZ MERY (RN)
Entity type:Individual
Prefix:
First Name:LUZ
Middle Name:MERY
Last Name:POBLANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5224
Mailing Address - Country:US
Mailing Address - Phone:631-793-4899
Mailing Address - Fax:
Practice Address - Street 1:59 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5224
Practice Address - Country:US
Practice Address - Phone:631-793-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY657533-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse