Provider Demographics
NPI:1336449065
Name:LEDERMAN, MARY FAIRE (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:FAIRE
Last Name:LEDERMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 CYPERT RD
Mailing Address - Street 2:
Mailing Address - City:WOODBOURNE
Mailing Address - State:NY
Mailing Address - Zip Code:12788-5379
Mailing Address - Country:US
Mailing Address - Phone:845-434-7056
Mailing Address - Fax:
Practice Address - Street 1:6 WIERK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2117
Practice Address - Country:US
Practice Address - Phone:845-292-5618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383133-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool