Provider Demographics
NPI:1992984736
Name:KOSECKI, DENISE M (LPN)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:M
Last Name:KOSECKI
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 1:171 SHANTY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-3415
Mailing Address - Country:US
Mailing Address - Phone:315-243-4294
Mailing Address - Fax:
Practice Address - Street 1:171 SHANTY CREEK RD
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-3415
Practice Address - Country:US
Practice Address - Phone:315-243-4294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1232481164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02165204Medicaid