Healthcare Provider Details

I. General information

NPI: 1871415216
Provider Name (Legal Business Name): RENATA GLEASON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD STE 2A
LIVERPOOL NY
13088-4886
US

IV. Provider business mailing address

5100 W TAFT RD STE 2A
LIVERPOOL NY
13088-4886
US

V. Phone/Fax

Practice location:
  • Phone: 315-631-6555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF359943-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: