Healthcare Provider Details

I. General information

NPI: 1508138686
Provider Name (Legal Business Name): MARYGRACE FRONK R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 S 4TH ST
FULTON NY
13069-1859
US

IV. Provider business mailing address

196 HAWK RD
FULTON NY
13069-4497
US

V. Phone/Fax

Practice location:
  • Phone: 315-593-5500
  • Fax:
Mailing address:
  • Phone: 315-593-7965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number2438901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: