Healthcare Provider Details

I. General information

NPI: 1790441376
Provider Name (Legal Business Name): HEATHER MARIE GANOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CENTRAL AVE
CORTLAND NY
13045-2746
US

IV. Provider business mailing address

3648 FAIRVIEW DR
CORTLAND NY
13045-9331
US

V. Phone/Fax

Practice location:
  • Phone: 607-753-5203
  • Fax: 607-758-5542
Mailing address:
  • Phone: 315-440-0279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number763738-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: