Healthcare Provider Details

I. General information

NPI: 1447691068
Provider Name (Legal Business Name): DAMETRESS MARYLAND HAUGHTON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DAMETRESS MARYLAND MAYERS LPN

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 2ND AVENUE
ROTTERDAM NY
12303
US

IV. Provider business mailing address

2303 2ND AVE
SCHENECTADY NY
12303
US

V. Phone/Fax

Practice location:
  • Phone: 518-881-8967
  • Fax:
Mailing address:
  • Phone: 518-881-8967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number274686-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: