Provider Demographics
NPI:1649488800
Name:DOUGHLAS, ROXANNE EUGENIA (LPN)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:EUGENIA
Last Name:DOUGHLAS
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 1:39 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1730
Mailing Address - Country:US
Mailing Address - Phone:845-891-0903
Mailing Address - Fax:
Practice Address - Street 1:29 WENDY DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6017
Practice Address - Country:US
Practice Address - Phone:845-298-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02179826164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02179826Medicaid