Basic Information
| Provider Information | |||||||||
| NPI: | 1417622135 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL NEW YORK FAMILY HEALTH NURSE PRACTITIONER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6303 YULEWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130399251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158765748 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5701 E. CIRCLE DR. | ||||||||
| Address2: | #264 SUITE 108 | ||||||||
| City: | CICERO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158765748 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | LYSIUS | ||||||||
| AuthorizedOfficialFirstName: | MIDZY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3158765748 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.