Healthcare Provider Details

I. General information

NPI: 1215617659
Provider Name (Legal Business Name): DONNA JEANNE LAROCQUE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 STATE ROUTE 374
DANNEMORA NY
12929
US

IV. Provider business mailing address

PO BOX 2000
DANNEMORA NY
12929-2000
US

V. Phone/Fax

Practice location:
  • Phone: 518-492-2511
  • Fax: 518-492-2503
Mailing address:
  • Phone: 518-492-2511
  • Fax: 518-492-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number352323
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: