Provider Demographics
NPI:1063723724
Name:SERVICE, VIVIENNE JOY (LPN)
Entity type:Individual
Prefix:MS
First Name:VIVIENNE
Middle Name:JOY
Last Name:SERVICE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:VIVIENNE
Other - Middle Name:JOY
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:19812 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1718
Mailing Address - Country:US
Mailing Address - Phone:718-468-9050
Mailing Address - Fax:
Practice Address - Street 1:19812 111TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-1718
Practice Address - Country:US
Practice Address - Phone:718-468-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233199-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse