Basic Information
| Provider Information | |||||||||
| NPI: | 1003013434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE BRASSARD | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.N | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 177 | ||||||||
| Address2: | |||||||||
| City: | MINEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129560177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189427753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 85 WASSON ST | ||||||||
| Address2: | |||||||||
| City: | WITHERBEE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129981650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185463218 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 063093-1 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02822104 | 05 | NY | MEDICAID |