Healthcare Provider Details

I. General information

NPI: 1689187395
Provider Name (Legal Business Name): JESSICA LEE HULETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 GREENWOOD ST
CANISTEO NY
14823-1233
US

IV. Provider business mailing address

120 GREENWOOD ST
CANISTEO NY
14823-1233
US

V. Phone/Fax

Practice location:
  • Phone: 607-698-4225
  • Fax:
Mailing address:
  • Phone: 607-698-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number626070
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: