Provider Demographics
NPI:1790441376
Name:GANOUNG, HEATHER MARIE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:GANOUNG
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 1:3648 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-9331
Mailing Address - Country:US
Mailing Address - Phone:315-440-0279
Mailing Address - Fax:
Practice Address - Street 1:60 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2746
Practice Address - Country:US
Practice Address - Phone:607-753-5203
Practice Address - Fax:607-758-5542
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY763738-1163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health