Provider Demographics
NPI:1154595643
Name:HERCULES, MARCIA ROXANNE (LPN)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:ROXANNE
Last Name:HERCULES
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 1:14 EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-3317
Mailing Address - Country:US
Mailing Address - Phone:631-813-2371
Mailing Address - Fax:
Practice Address - Street 1:14 EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-3317
Practice Address - Country:US
Practice Address - Phone:631-813-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281269-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02927888Medicaid