Basic Information
Provider Information | |||||||||
NPI: | 1114552361 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MERKWA | ||||||||
FirstName: | LEEANNE | ||||||||
MiddleName: | JESSICA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEMARCO | ||||||||
OtherFirstName: | LEEANNE | ||||||||
OtherMiddleName: | JESSICA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3392 DOLPHIN DR | ||||||||
Address2: |   | ||||||||
City: | BLASDELL | ||||||||
State: | NY | ||||||||
PostalCode: | 142192252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7162440332 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1050 NIAGARA ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142132001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7167104399 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2020 | ||||||||
LastUpdateDate: | 03/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 594376 | NY | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.