Basic Information
Provider Information | |||||||||
NPI: | 1134306442 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DILLON | ||||||||
FirstName: | MAUREEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 621 | ||||||||
Address2: | 1131 US ROUTE 9 | ||||||||
City: | SCHROON LAKE | ||||||||
State: | NY | ||||||||
PostalCode: | 12870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5183515019 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2842 PLANK ROAD | ||||||||
Address2: |   | ||||||||
City: | MORIAH CENTER | ||||||||
State: | NY | ||||||||
PostalCode: | 12961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5185463218 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2008 | ||||||||
LastUpdateDate: | 01/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2891161 | NY | Y |   | Nursing Service Providers | Licensed Practical Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 02903175 | 05 | NY |   | MEDICAID |