Provider Demographics
NPI:1740902212
Name:MOUNTAIN, DEBRA LOU (LPN)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:LOU
Last Name:MOUNTAIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:LOU
Other - Last Name:WILK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:15 SIMS AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830
Mailing Address - Country:US
Mailing Address - Phone:419-239-7586
Mailing Address - Fax:
Practice Address - Street 1:15 SIMS AVENUE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830
Practice Address - Country:US
Practice Address - Phone:419-239-7586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299947-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse