Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 021312-1 | NY |
NPI | 1023344496 |
---|---|
Provider Name | Lisa M Tyra-Herrick |
First Address | Rushville, NY 14544-9681 |
Second Address | Rushville, NY 14544-9681 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2009 |
Last Update Date | 20/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00618199 | (05) | NY |