Provider Demographics
NPI:1124291158
Name:RADIGAN, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:RADIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FREDERICK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6251
Mailing Address - Country:US
Mailing Address - Phone:315-457-1288
Mailing Address - Fax:315-457-1288
Practice Address - Street 1:125 FREDERICK DR
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6251
Practice Address - Country:US
Practice Address - Phone:315-457-1288
Practice Address - Fax:315-457-1288
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139054-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse