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General NPI Number Information
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NPI Number | 1912524372
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Entity Type | Individual
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Provider Name | LEATRICE KIICHELLE DYER LPN
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Gender | Female
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Dates
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Enumeration Date | 07/01/2020
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Last Update Date | 07/01/2020
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Provider Practice Location Address
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Address Line | 23 BRITTANY CT
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City | NORTHPORT
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State | NY
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Zip | 11768-3225
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Country | US
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Telephone | 631-374-0977
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Fax |
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Provider Business Mailing Address
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Address Line | 282 W 15TH ST
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City | DEER PARK
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State | NY
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Zip | 11729-6304
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Country | US
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Telephone | 631-374-0974
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 338518
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License Number State | NY
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