1215042692 NPI number — MRS. SANDRA CARROLL FISH RN BSN MS FNPC

Table of content: MRS. SANDRA CARROLL FISH RN BSN MS FNPC (NPI 1215042692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215042692 NPI number — MRS. SANDRA CARROLL FISH RN BSN MS FNPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISH
Provider First Name:
SANDRA
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN BSN MS FNPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215042692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 ENGLISH AVENUE
Provider Second Line Business Mailing Address:
PO BOX 515
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13346-0515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-824-1422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1657 SUNSET AVENUE
Provider Second Line Business Practice Location Address:
HERITAGE HEALTH CARE CENTER
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-797-7392
Provider Business Practice Location Address Fax Number:
315-797-0836
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  330513 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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