Provider Demographics
NPI:1215297320
Name:RIDDICK, VERONICA LAVERNE (LPN)
Entity type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:LAVERNE
Last Name:RIDDICK
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 1:33 W 138TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1754
Mailing Address - Country:US
Mailing Address - Phone:917-402-0083
Mailing Address - Fax:
Practice Address - Street 1:33 W 138TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1754
Practice Address - Country:US
Practice Address - Phone:917-402-0083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306202-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid