Healthcare Provider Details

I. General information

NPI: 1396769048
Provider Name (Legal Business Name): JUDY NORMAN WILBURN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROME CBOC OF THE SYRACUSE VA 125 BROOKLEY AVE.
ROME NY
13441
US

IV. Provider business mailing address

1407 N MADISON ST
ROME NY
13440-2707
US

V. Phone/Fax

Practice location:
  • Phone: 315-334-7100
  • Fax: 315-334-7171
Mailing address:
  • Phone: 315-334-4662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF330964-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: