Provider Demographics
NPI:1386888089
Name:SCOTTO, ANGELIQUE GRACE (LPN)
Entity type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:GRACE
Last Name:SCOTTO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:ANGELIQUE
Other - Middle Name:GRACE
Other - Last Name:HLAVAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:200 AMOS AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2320
Mailing Address - Country:US
Mailing Address - Phone:516-705-5784
Mailing Address - Fax:
Practice Address - Street 1:204 SAINT MARKS PL
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1802
Practice Address - Country:US
Practice Address - Phone:516-705-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243356164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01767633Medicaid