Healthcare Provider Details

I. General information

NPI: 1376552422
Provider Name (Legal Business Name): ELLEN GOODWATER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 GENESEE ST SUITE 2
ONEIDA NY
13421-2658
US

IV. Provider business mailing address

357 GENESEE ST STE 2
ONEIDA NY
13421-2658
US

V. Phone/Fax

Practice location:
  • Phone: 315-363-2123
  • Fax: 315-363-4651
Mailing address:
  • Phone: 315-363-2123
  • Fax: 315-363-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF331906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: