Provider Demographics
NPI:1881979771
Name:CRESPO, GLORIA M (LPN)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:CRESPO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 S MAIN ST # 344
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3353
Mailing Address - Country:US
Mailing Address - Phone:646-450-8455
Mailing Address - Fax:646-570-1986
Practice Address - Street 1:169 S MAIN ST # 344
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3353
Practice Address - Country:US
Practice Address - Phone:646-450-8455
Practice Address - Fax:646-570-1986
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168646164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03382414Medicaid