MEDICARE: MRS. CARISSA PACHECO 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	308220	NY

General Provider Information

NPI Number	:	1760843858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARISSA PACHECO LPN

Provider Business Mailing Address
First Line	:	538 B LIBERTY CORNERS RD
Second Line	:
City	:	PINE ISLAND
State	:	NY
Zip	:	10969
Country	:	US
Telephone Number	:	845-709-1578
Fax Number	:

Provider Business Practice Location Address
First Line	:	538 B LIBERTY CORNERS RD
Second Line	:
City	:	PINE ISLAND
State	:	NY
Zip	:	10969
Country	:	US
Telephone Number	:	845-709-1578
Fax Number	:

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

Provider Enumeration Date	:	03/16/2016
Last Update Date	:	03/16/2016

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