Healthcare Provider Details

I. General information

NPI: 1023096906
Provider Name (Legal Business Name): DIRETTA N O'LARRY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 442
APO AE
09165
DE

IV. Provider business mailing address

CMR 412 BOX 891
APO AE
09165
DE

V. Phone/Fax

Practice location:
  • Phone: 496221172274
  • Fax:
Mailing address:
  • Phone: 3286656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number279748-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: