=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558254102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOLLY ALPHA LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2025
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 STATE ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14614-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-454-3550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 EMPIRE BLVD APT 13
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14580-2133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-520-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 342960-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------