Provider Demographics
NPI:1255629564
Name:VADAX, MARY ELLEN CATHERINE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:CATHERINE
Last Name:VADAX
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 1:61 PINE EDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940
Mailing Address - Country:US
Mailing Address - Phone:631-235-3386
Mailing Address - Fax:
Practice Address - Street 1:61 PINE EDGE DR
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940
Practice Address - Country:US
Practice Address - Phone:631-235-3386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116204-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse