Provider Demographics
NPI:1124145248
Name:MLOTT, CARLA JEANNE (LPN)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:JEANNE
Last Name:MLOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 COUNTY ROUTE 119
Mailing Address - Street 2:
Mailing Address - City:CANISTEO
Mailing Address - State:NY
Mailing Address - Zip Code:14823-9654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 COUNTY ROUTE 119
Practice Address - Street 2:
Practice Address - City:CANISTEO
Practice Address - State:NY
Practice Address - Zip Code:14823-9654
Practice Address - Country:US
Practice Address - Phone:607-698-2641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176416164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049874Medicaid