Healthcare Provider Details

I. General information

NPI: 1750678165
Provider Name (Legal Business Name): MRS. ILLONDA CHEREESE MCCANTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ILLONDA CHEREESE MCCANTS RN

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 BERNARD ST
ROCHESTER NY
14621-4825
US

IV. Provider business mailing address

338 BERNARD ST
ROCHESTER NY
14621-4825
US

V. Phone/Fax

Practice location:
  • Phone: 347-543-0291
  • Fax: 585-266-7733
Mailing address:
  • Phone: 347-543-0291
  • Fax: 585-266-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number710581
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number10276448
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: