Healthcare Provider Details

I. General information

NPI: 1538613377
Provider Name (Legal Business Name): ROSELLA MARIE PICKENS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSELLA MARIE PURCELL LPN

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 HAMILTON AVE
MONTICELLO NY
12701-1319
US

IV. Provider business mailing address

5393 STATE ROUTE 55
LIBERTY NY
12754-2943
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-8080
  • Fax:
Mailing address:
  • Phone: 845-791-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2936699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: