MEDICARE: MRS. KHORIASA MARIE RUFFELL LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	332724-01	NY

General Provider Information

NPI Number	:	1154119808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KHORIASA MARIE RUFFELL LPN

Provider Business Mailing Address
First Line	:	15 SUFFERN PL STE A
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-5566
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6 WALNUT DR
Second Line	:
City	:	PLEASANT VALLEY
State	:	NY
Zip	:	12569-6934
Country	:	US
Telephone Number	:	845-366-9212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2025
Last Update Date	:	04/30/2025

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