MEDICARE: COMPASSIONATE PSYCHIATRIC NP CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1942754015	OTHER	NY	NPI TYPE 1

General Provider Information

NPI Number	:	1083267959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPASSIONATE PSYCHIATRIC NP CARE PLLC

Provider Business Mailing Address
First Line	:	5700 W GENESEE ST STE 132
Second Line	:
City	:	CAMILLUS
State	:	NY
Zip	:	13031-3212
Country	:	US
Telephone Number	:	315-362-2540
Fax Number	:	315-671-1786

Provider Business Practice Location Address
First Line	:	5700 W GENESEE ST STE 132
Second Line	:
City	:	CAMILLUS
State	:	NY
Zip	:	13031-3212
Country	:	US
Telephone Number	:	315-362-2540
Fax Number	:	315-671-1786

Authorized Official
Title or Position	:	OWNER/NURSE PRACTITIONER
Name	:	SHELLY LYNN PETERS
Credential	:	PMHNP-BC
Telephone Number	:	315-362-2540

Provider Enumeration Date	:	07/19/2019
Last Update Date	:	08/20/2019

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