Provider Demographics
NPI:1740335660
Name:DAMON, VENITA ALEXANDRA (LPN)
Entity type:Individual
Prefix:MS
First Name:VENITA
Middle Name:ALEXANDRA
Last Name:DAMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:VENITA
Other - Middle Name:ALEXANDRA
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12038 231ST STREET
Mailing Address - Street 2:CAMBRIA HEIGHTS JAMAICA
Mailing Address - City:QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-2220
Mailing Address - Country:US
Mailing Address - Phone:718-527-9315
Mailing Address - Fax:718-527-9315
Practice Address - Street 1:12038 231ST STREET
Practice Address - Street 2:CAMBRIA HEIGHTS JAMAICA
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11411-2220
Practice Address - Country:US
Practice Address - Phone:718-527-9315
Practice Address - Fax:718-527-9315
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2438311164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01690239Medicaid