Provider Demographics
NPI:1427424662
Name:KICKBUSH, ALYSE RENEE (LPN)
Entity type:Individual
Prefix:MISS
First Name:ALYSE
Middle Name:RENEE
Last Name:KICKBUSH
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 1:5165 ROUTE 62
Mailing Address - Street 2:
Mailing Address - City:CONEWANGO VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14726-9713
Mailing Address - Country:US
Mailing Address - Phone:716-352-1593
Mailing Address - Fax:
Practice Address - Street 1:5165 ROUTE 62
Practice Address - Street 2:
Practice Address - City:CONEWANGO VALLEY
Practice Address - State:NY
Practice Address - Zip Code:14726-9713
Practice Address - Country:US
Practice Address - Phone:716-352-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322718164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse