Healthcare Provider Details

I. General information

NPI: 1376072033
Provider Name (Legal Business Name): MICHELLE D FELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE MCPHERSON RN

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 POLK ST STE 300
WATERTOWN NY
13601-2770
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-782-7445
  • Fax: 315-779-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number275799-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number733717-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: