Healthcare Provider Details

I. General information

NPI: 1326027061
Provider Name (Legal Business Name): OTSELIC VALLEY FAMILY HEALTH NP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1594 STATE HIGHWAY RTE 26
SOUTH OTSELIC NY
13155
US

IV. Provider business mailing address

PO BOX 90
SOUTH OTSELIC NY
13155
US

V. Phone/Fax

Practice location:
  • Phone: 315-653-7515
  • Fax: 315-653-7517
Mailing address:
  • Phone: 315-653-7515
  • Fax: 315-653-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF330475
License Number StateNY

VIII. Authorized Official

Name: JUDY A PENDELL-MCKEE
Title or Position: FAMILY NURSE PRACTITIONER OWNER
Credential: FNP
Phone: 315-653-7515