Healthcare Provider Details

I. General information

NPI: 1366816498
Provider Name (Legal Business Name): TINA REDICK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W FALLS RD
WEST FALLS NY
14170-9711
US

IV. Provider business mailing address

522 W FALLS RD
WEST FALLS NY
14170-9711
US

V. Phone/Fax

Practice location:
  • Phone: 716-425-0289
  • Fax:
Mailing address:
  • Phone: 716-425-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number179999
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: