Provider Demographics
NPI:1144656612
Name:RODRIGUEZ, LADY DAYANA (MSSPED)
Entity type:Individual
Prefix:MRS
First Name:LADY
Middle Name:DAYANA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MSSPED
Other - Prefix:MISS
Other - First Name:LADY
Other - Middle Name:DAYANA
Other - Last Name:OROZCO VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:576 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1333
Mailing Address - Country:US
Mailing Address - Phone:917-517-0169
Mailing Address - Fax:
Practice Address - Street 1:100 N PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4157
Practice Address - Country:US
Practice Address - Phone:516-678-0707
Practice Address - Fax:516-678-5990
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY584153111171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33628Medicaid