Healthcare Provider Details

I. General information

NPI: 1427493683
Provider Name (Legal Business Name): SUSAN MARIE VOLLES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN MARIE EGNACZAK NP

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 MEDICAL CENTER DR SUITE 206
FAYETTEVILLE NY
13066
US

IV. Provider business mailing address

4206 MEDICAL CENTER DR ST JOSEPH'S CENTER FOR WOUND CARE
FAYETTEVILLE NY
13066
US

V. Phone/Fax

Practice location:
  • Phone: 315-329-7770
  • Fax: 315-329-7772
Mailing address:
  • Phone: 315-329-7770
  • Fax: 315-329-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF300837
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: