Provider Demographics
NPI:1720302854
Name:CAMPO, JON WILLIAM (LPN)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:WILLIAM
Last Name:CAMPO
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 1:332 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9559
Mailing Address - Country:US
Mailing Address - Phone:585-392-0168
Mailing Address - Fax:
Practice Address - Street 1:150 STATE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14614-1353
Practice Address - Country:US
Practice Address - Phone:585-454-3550
Practice Address - Fax:585-232-4231
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250970-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse