Provider Demographics
NPI:1215318498
Name:EXTAVOUR, HERUTE-AMLAK (LPN)
Entity type:Individual
Prefix:
First Name:HERUTE-AMLAK
Middle Name:
Last Name:EXTAVOUR
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 1:350 VANDERBILT AVE APT 6D
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3537
Mailing Address - Country:US
Mailing Address - Phone:347-797-8726
Mailing Address - Fax:
Practice Address - Street 1:350 VANDERBILT AVE APT 6D
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-3537
Practice Address - Country:US
Practice Address - Phone:347-797-8726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315213164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse