Provider Demographics
NPI:1548313703
Name:LUCIDO-FULTON, ROXANNE P (LPN)
Entity type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:P
Last Name:LUCIDO-FULTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:ROXANNE
Other - Middle Name:P
Other - Last Name:LUCIDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:59 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2532
Mailing Address - Country:US
Mailing Address - Phone:631-928-8095
Mailing Address - Fax:
Practice Address - Street 1:59 PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2532
Practice Address - Country:US
Practice Address - Phone:631-928-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114262-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01709659Medicaid