Provider Demographics
NPI:1700132255
Name:LEBOURVEAU, DYLAN MICHAEL (LPN)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:MICHAEL
Last Name:LEBOURVEAU
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 MAPLECREST DR
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1964
Mailing Address - Country:US
Mailing Address - Phone:631-466-2457
Mailing Address - Fax:
Practice Address - Street 1:1145 MONTAUK HWY STE 1
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4909
Practice Address - Country:US
Practice Address - Phone:631-666-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303092164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse