Healthcare Provider Details

I. General information

NPI: 1194098442
Provider Name (Legal Business Name): JENNIFER LYNNE GORMAN-FECCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 KENNEDY PKWY
CORTLAND NY
13045-1409
US

IV. Provider business mailing address

586 BABCOCK RD
TULLY NY
13159-3246
US

V. Phone/Fax

Practice location:
  • Phone: 607-753-9105
  • Fax:
Mailing address:
  • Phone: 315-391-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number454672
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: