Provider Demographics
NPI:1700872496
Name:LETHAM, LINDA W (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:W
Last Name:LETHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1901
Mailing Address - Country:US
Mailing Address - Phone:315-769-1667
Mailing Address - Fax:315-769-6945
Practice Address - Street 1:181 MAPLE ST STE C
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1052
Practice Address - Country:US
Practice Address - Phone:315-769-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302461363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02166145Medicaid
NYMLD383961OtherDEA
NYMLD383961OtherDEA
NY02166145Medicaid