Individual
AIESHA MACKBENNETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
28 CARR LN, MEDFORD, NY 11763-1071
(631) 846-6194
Mailing address
28 CARR LANE, MEDFORD, NY 11763
(631) 846-6194
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
319985-1
NY
Other
Enumeration date
10/31/2014
Last updated
10/31/2014
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