Provider Demographics
NPI:1770150526
Name:JEAN, LOURDES AGLAEE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:AGLAEE
Last Name:JEAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4406
Mailing Address - Country:US
Mailing Address - Phone:718-869-8000
Mailing Address - Fax:
Practice Address - Street 1:1711 BROOKHAVEN AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4406
Practice Address - Country:US
Practice Address - Phone:718-869-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY506185163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care