MEDICARE: MRS. KOREY LEIGH FANTACONE MS, OTR/L

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1437646585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KOREY LEIGH FANTACONE MS, OTR/L

Provider Business Mailing Address
First Line	:	159 WEST 1ST STREET
Second Line	:
City	:	OSWEGO
State	:	NY
Zip	:	13126
Country	:	US
Telephone Number	:	315-456-8260
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 VILLAGE BLVD S
Second Line	:
City	:	BALDWINSVILLE
State	:	NY
Zip	:	13027-3369
Country	:	US
Telephone Number	:	315-215-6991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2018
Last Update Date	:	10/28/2022

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