Provider Demographics
NPI:1750953998
Name:BERNARD, TINA MARIE (LPN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BERNARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6009 BOYD ROAD LOT 36
Mailing Address - Street 2:P.O. BOX 280
Mailing Address - City:SODUS
Mailing Address - State:NY
Mailing Address - Zip Code:14551
Mailing Address - Country:US
Mailing Address - Phone:315-359-1976
Mailing Address - Fax:
Practice Address - Street 1:101 COBBLESTONE TERRACE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-332-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240699164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse