Healthcare Provider Details

I. General information

NPI: 1265433593
Provider Name (Legal Business Name): NORTHERN NY INFUSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18564 US ROUTE 11
WATERTOWN NY
13601-5900
US

IV. Provider business mailing address

18564 US ROUTE 11
WATERTOWN NY
13601-5900
US

V. Phone/Fax

Practice location:
  • Phone: 315-785-5436
  • Fax: 315-786-3497
Mailing address:
  • Phone: 315-785-5436
  • Fax: 315-786-3497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number9957L001
License Number StateNY

VIII. Authorized Official

Name: MRS. LINDA SUE STEVENS
Title or Position: OFFICE/BILLING MANAGER
Credential:
Phone: 315-785-5436