Provider Demographics
NPI:1962752170
Name:ECCLESTON, SANDRA A
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:ECCLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:A
Other - Last Name:ECCLESTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:500 GOLF COURT
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:917-328-9108
Mailing Address - Fax:
Practice Address - Street 1:500 GOLF CT
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3542
Practice Address - Country:US
Practice Address - Phone:917-328-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310438-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse