Provider Demographics
NPI:1649705229
Name:MYERS, JENNIFER (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MYERS
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 1:104 MOONLIGHT WALK
Mailing Address - Street 2:104
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4923
Mailing Address - Country:US
Mailing Address - Phone:631-994-5144
Mailing Address - Fax:
Practice Address - Street 1:104 MOONLIGHT WALK
Practice Address - Street 2:104
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4923
Practice Address - Country:US
Practice Address - Phone:631-994-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328546164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse