Healthcare Provider Details

I. General information

NPI: 1992149462
Provider Name (Legal Business Name): DEBORAH LU AMIDON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 JAMESVILLE AVE
SYRACUSE NY
13210-3211
US

IV. Provider business mailing address

345 JAMESVILLE AVE
SYRACUSE NY
13210-3211
US

V. Phone/Fax

Practice location:
  • Phone: 315-435-4563
  • Fax:
Mailing address:
  • Phone: 315-435-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number7471744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: