Healthcare Provider Details

I. General information

NPI: 1427309814
Provider Name (Legal Business Name): EMILY ELIZABETH MAYTUM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY ELIZABETH GRIFFITH FNP

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CENTRAL AVE LOGRASSO HALL STUDENT HEALTH CENTER
FREDONIA NY
14063-1127
US

IV. Provider business mailing address

280 CENTRAL AVE LOGRASSO HALL STUDENT HEALTH CENTER
FREDONIA NY
14063-1127
US

V. Phone/Fax

Practice location:
  • Phone: 716-673-3131
  • Fax: 716-673-4722
Mailing address:
  • Phone: 716-673-3131
  • Fax: 716-673-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF337466
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: