Basic Information
| Provider Information | |||||||||
| NPI: | 1477170702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | D'AGOSTINO | ||||||||
| FirstName: | LUCILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 LYON PL | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136692586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153932314 | ||||||||
| FaxNumber: | 3153933873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2020 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 346045 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 346045 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 06505311 | 05 | NY | MEDICAID |