Healthcare Provider Details

I. General information

NPI: 1801878640
Provider Name (Legal Business Name): VANNA A REISMAN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 FRANKLIN PARK DR.
EAST SYRACUSE NY
13057
US

IV. Provider business mailing address

824 FRANKLIN PARK DR.
EAST SYRACUSE NY
13057
US

V. Phone/Fax

Practice location:
  • Phone: 315-432-1048
  • Fax: 315-432-9219
Mailing address:
  • Phone: 315-432-1048
  • Fax: 315-432-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberF360502-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF0005381
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: