Provider Demographics
NPI:1194782425
Name:IPPOLITO, LORAINE (NP)
Entity type:Individual
Prefix:
First Name:LORAINE
Middle Name:
Last Name:IPPOLITO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1732
Mailing Address - Country:US
Mailing Address - Phone:716-972-0279
Mailing Address - Fax:716-972-0271
Practice Address - Street 1:3675 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1732
Practice Address - Country:US
Practice Address - Phone:716-972-0279
Practice Address - Fax:716-972-0271
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3002671363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00021054903OtherUNIVERA
NY040426002812OtherFIDELIS CARE #
NY9513162OtherIHA #
NY02794365Medicaid
NY00021054902OtherUNIVERA
NY180048BJOtherPREFERRED CARE
NY000560087008OtherBCBS
NY000560087007OtherBC/BS
NYRB7180Medicare PIN
NY000560087008OtherBCBS
NY02794365Medicaid
NYP00189076Medicare PIN