Provider Demographics
NPI:1699149815
Name:YOUNG, CHAMPAINE JAYLA
Entity type:Individual
Prefix:
First Name:CHAMPAINE
Middle Name:JAYLA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHAMPAINE
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:109 MONTICELLO PL
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2713
Mailing Address - Country:US
Mailing Address - Phone:716-480-4242
Mailing Address - Fax:
Practice Address - Street 1:109 MONTICELLO PL
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2713
Practice Address - Country:US
Practice Address - Phone:716-480-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-26
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2926061164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse