Healthcare Provider Details

I. General information

NPI: 1194040550
Provider Name (Legal Business Name): MARIA RENEE HAYDUKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MADISON ST
SYRACUSE NY
13210-2319
US

IV. Provider business mailing address

918 BEVERLY DR
SYRACUSE NY
13219-2802
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-7728
  • Fax:
Mailing address:
  • Phone: 315-488-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number519536
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: