Provider Demographics
NPI:1285880625
Name:DEGRAFF-DACEY, ANGIE L (LPN)
Entity type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:L
Last Name:DEGRAFF-DACEY
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 1:160 FLORENTIA LN E
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830
Mailing Address - Country:US
Mailing Address - Phone:607-207-1137
Mailing Address - Fax:
Practice Address - Street 1:160 FLORENTIA LN E
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830
Practice Address - Country:US
Practice Address - Phone:607-207-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293945164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03032937Medicaid