Provider Demographics
NPI:1265833156
Name:JANICKI, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:JANICKI
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 1:6075 JUDD RD
Mailing Address - Street 2:
Mailing Address - City:ORISKANY
Mailing Address - State:NY
Mailing Address - Zip Code:13424-4218
Mailing Address - Country:US
Mailing Address - Phone:315-732-0594
Mailing Address - Fax:
Practice Address - Street 1:6075 JUDD RD
Practice Address - Street 2:
Practice Address - City:ORISKANY
Practice Address - State:NY
Practice Address - Zip Code:13424-4218
Practice Address - Country:US
Practice Address - Phone:315-765-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302349-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health