Basic Information
| Provider Information | |||||||||
| NPI: | 1043839285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3268 US ROUTE 11 | ||||||||
| Address2: | |||||||||
| City: | LA FAYETTE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130849773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154504144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2031 DREAM CATCHER PLZ | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152315400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 06/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 345956 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.