Provider Demographics
NPI:1962739243
Name:EGBETOKUM, ANIKE ALICE (LPN)
Entity type:Individual
Prefix:MS
First Name:ANIKE
Middle Name:ALICE
Last Name:EGBETOKUM
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 1:38 RIDER AVE
Mailing Address - Street 2:APT 521
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3900
Mailing Address - Country:US
Mailing Address - Phone:631-295-7865
Mailing Address - Fax:
Practice Address - Street 1:38 RIDER AVE
Practice Address - Street 2:APT 521
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3900
Practice Address - Country:US
Practice Address - Phone:631-295-7865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-08
Last Update Date:2009-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299117-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse