Healthcare Provider Details

I. General information

NPI: 1851424857
Provider Name (Legal Business Name): JODI MARIE CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WESTFALL RD
ROCHESTER NY
14620-4610
US

IV. Provider business mailing address

2166 COUNTY ROUTE 90
WAYLAND NY
14572-9531
US

V. Phone/Fax

Practice location:
  • Phone: 585-461-8683
  • Fax: 585-461-8545
Mailing address:
  • Phone: 585-728-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number1959731
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: