Healthcare Provider Details

I. General information

NPI: 1235672452
Provider Name (Legal Business Name): MICHELLE PUTNAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2016
Last Update Date: 11/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 SCHLEGEL RD
WEBSTER NY
14580-8506
US

IV. Provider business mailing address

25 CHIPPENHAM DR
PENFIELD NY
14526-1909
US

V. Phone/Fax

Practice location:
  • Phone: 585-265-2500
  • Fax:
Mailing address:
  • Phone: 585-474-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number508047-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: