Provider Demographics
NPI:1376617480
Name:WOMEN'S WELLNESS PLACE, PC
Entity Type:Organization
Organization Name:WOMEN'S WELLNESS PLACE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANTELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DALPE-FUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-478-1158
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1640
Mailing Address - Country:US
Mailing Address - Phone:315-478-1158
Mailing Address - Fax:315-478-3014
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1640
Practice Address - Country:US
Practice Address - Phone:315-478-1158
Practice Address - Fax:315-478-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02375359Medicaid
NYAA0510Medicare PIN