Healthcare Provider Details

I. General information

NPI: 1124932439
Provider Name (Legal Business Name): NIKKI ALICIA VENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 N SALINA ST
SYRACUSE NY
13203-1755
US

IV. Provider business mailing address

329 N SALINA ST
SYRACUSE NY
13203-1755
US

V. Phone/Fax

Practice location:
  • Phone: 315-708-9569
  • Fax:
Mailing address:
  • Phone: 315-434-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number38606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: