Basic Information
| Provider Information | |||||||||
| NPI: | 1316253768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARNUM | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 SOUTHERN HILLS CIR | ||||||||
| Address2: | |||||||||
| City: | HENRIETTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144679709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855208911 | ||||||||
| FaxNumber: | 5855480107 | ||||||||
| Practice Location | |||||||||
| Address1: | 5232 WITZ DR | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F305388 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 305388 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | F305388 | 01 | LICENSE | OTHER |