Healthcare Provider Details

I. General information

NPI: 1336784479
Provider Name (Legal Business Name): WENDY SUE COLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

3810 RT 69
MEXICO NY
13114
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-2630
  • Fax:
Mailing address:
  • Phone: 315-402-5625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number504750
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: