Basic Information
| Provider Information | |||||||||
| NPI: | 1578796181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GANRORMIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEE CAN PRESCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26 PAWTUCKET ROW | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141273920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166627456 | ||||||||
| FaxNumber: | 7166672272 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 CENTRE DR | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141274100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166672294 | ||||||||
| FaxNumber: | 7166672272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2009 | ||||||||
| LastUpdateDate: | 08/29/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WETTLAUFER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7166672294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NURSE PRACTITIONER | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | 353200 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | School |
ID Information
| ID | Type | State | Issuer | Description | 21122 | 01 | NY | NYS DEPARTMENT OF HEALTH | OTHER |