Healthcare Provider Details

I. General information

NPI: 1750764429
Provider Name (Legal Business Name): ELLETTA EDNA HORTH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ATWELL RD
COOPERSTOWN NY
13326-1301
US

IV. Provider business mailing address

1 ATWELL RD
COOPERSTOWN NY
13326-1301
US

V. Phone/Fax

Practice location:
  • Phone: 607-547-3456
  • Fax:
Mailing address:
  • Phone: 607-547-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF339822-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: