Healthcare Provider Details

I. General information

NPI: 1811407745
Provider Name (Legal Business Name): LANEASHA MARIE EUDELL NPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 W ONONDAGA ST
SYRACUSE NY
13202-3207
US

IV. Provider business mailing address

213 SUNNYBROOK DR
SYRACUSE NY
13219-1231
US

V. Phone/Fax

Practice location:
  • Phone: 315-478-2030
  • Fax:
Mailing address:
  • Phone: 315-604-1974
  • Fax: 315-800-6476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402314
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: