Provider Demographics
NPI:1417405796
Name:BACCHUS, MARIA (LPN)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BACCHUS
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 1:11 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-8205
Mailing Address - Country:US
Mailing Address - Phone:347-721-4930
Mailing Address - Fax:
Practice Address - Street 1:263 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1224
Practice Address - Country:US
Practice Address - Phone:631-419-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277895164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse