Provider Demographics
NPI:1720442213
Name:LANCELOT, DIONISIA (LPN)
Entity Type:Individual
Prefix:
First Name:DIONISIA
Middle Name:
Last Name:LANCELOT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DIONISIA
Other - Middle Name:
Other - Last Name:LANCELOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2363 PITKIN AVENUE APT# 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207
Mailing Address - Country:US
Mailing Address - Phone:347-339-9138
Mailing Address - Fax:
Practice Address - Street 1:2363 PITKIN AVE APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3855
Practice Address - Country:US
Practice Address - Phone:347-339-9138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3249591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12B749158Medicaid