Healthcare Provider Details

I. General information

NPI: 1336980754
Provider Name (Legal Business Name): MRS. SYLVIA A OBANGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON ST
ELMIRA NY
14901-2849
US

IV. Provider business mailing address

454 ALBERT ST APT A APT A
ELMIRA NY
14904-2312
US

V. Phone/Fax

Practice location:
  • Phone: 315-380-9332
  • Fax:
Mailing address:
  • Phone: 315-380-9332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number783963-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: