Healthcare Provider Details

I. General information

NPI: 1710243613
Provider Name (Legal Business Name): LEISA KAY DWYER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 WEBSTER STREET DAVIS ELEMENTARY
MALONE NY
12953
US

IV. Provider business mailing address

P.O. BOX 847 42 HUSKIE LANE
MALONE NY
12953
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-7802
  • Fax: 518-483-6390
Mailing address:
  • Phone: 518-483-7800
  • Fax: 518-483-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number493695-1(RNLICENSE)
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: