Provider Demographics
NPI:1215400148
Name:VANCAMP, KARISSA KELLEY
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:KELLEY
Last Name:VANCAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:PHELPS
Mailing Address - State:NY
Mailing Address - Zip Code:14532-9522
Mailing Address - Country:US
Mailing Address - Phone:315-719-1644
Mailing Address - Fax:
Practice Address - Street 1:778 FISHER RD
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:NY
Practice Address - Zip Code:14532-9522
Practice Address - Country:US
Practice Address - Phone:315-719-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321976-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY321976-1Medicaid