Provider Demographics
NPI:1538613377
Name:PICKENS, ROSELLA MARIE (LPN)
Entity type:Individual
Prefix:
First Name:ROSELLA
Middle Name:MARIE
Last Name:PICKENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ROSELLA
Other - Middle Name:MARIE
Other - Last Name:PURCELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5393 STATE ROUTE 55
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-2943
Mailing Address - Country:US
Mailing Address - Phone:845-791-0977
Mailing Address - Fax:
Practice Address - Street 1:17 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1319
Practice Address - Country:US
Practice Address - Phone:845-794-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2936699164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse