Healthcare Provider Details

I. General information

NPI: 1558663856
Provider Name (Legal Business Name): JUDITH HUNTER FAGER PHD, RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/14/2020
Certification Date: 11/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 N BURDICK ST STE 206A
EAST SYRACUSE NY
13057-9464
US

IV. Provider business mailing address

5900 N BURDICK ST STE 206A
EAST SYRACUSE NY
13057-9464
US

V. Phone/Fax

Practice location:
  • Phone: 315-627-0383
  • Fax: 731-202-0964
Mailing address:
  • Phone: 315-627-0383
  • Fax: 731-202-0964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF3000731
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF3313801
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: