Healthcare Provider Details

I. General information

NPI: 1013539196
Provider Name (Legal Business Name): LETTIE EDENS HURSH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 HILLARY DR
ROCHESTER NY
14624-5207
US

IV. Provider business mailing address

73 HILLARY DR
ROCHESTER NY
14624-5207
US

V. Phone/Fax

Practice location:
  • Phone: 585-944-9385
  • Fax:
Mailing address:
  • Phone: 585-944-9385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number22472-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: