Provider Demographics
NPI:1679701825
Name:SPIDELL, JACI (LPN)
Entity type:Individual
Prefix:
First Name:JACI
Middle Name:
Last Name:SPIDELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14212-1056
Mailing Address - Country:US
Mailing Address - Phone:716-430-7908
Mailing Address - Fax:
Practice Address - Street 1:2250 WEHRLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7034
Practice Address - Country:US
Practice Address - Phone:716-276-2123
Practice Address - Fax:716-276-2129
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297210164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse