Healthcare Provider Details

I. General information

NPI: 1578398897
Provider Name (Legal Business Name): HALEY FULLER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 12/16/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLAZA 1ST FL
SYRACUSE NY
13202
US

IV. Provider business mailing address

90 PRESIDENTIAL PLAZA 1ST FL
SYRACUSE NY
13202
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5210
  • Fax: 315-464-2141
Mailing address:
  • Phone: 315-464-5210
  • Fax: 315-464-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF002321-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: