Healthcare Provider Details

I. General information

NPI: 1235473315
Provider Name (Legal Business Name): RENEE SMALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 TILDEN AVE
UTICA NY
13501-4100
US

IV. Provider business mailing address

6906 CHASE LAKE RD
GLENFIELD NY
13343-2112
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-4040
  • Fax: 315-733-3869
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number278806-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: