Healthcare Provider Details

I. General information

NPI: 1902105273
Provider Name (Legal Business Name): NICOLE MARIE FETZER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 07/22/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 GREENFIELD PKWY STE 105
LIVERPOOL NY
13088
US

IV. Provider business mailing address

PO BOX 2337
SYRACUSE NY
13220-2337
US

V. Phone/Fax

Practice location:
  • Phone: 315-451-6911
  • Fax: 315-451-1540
Mailing address:
  • Phone: 315-422-6705
  • Fax: 315-422-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number543801
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number543801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: