Provider Demographics
NPI:1922138148
Name:FEARON, MISTY MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MELISSA
Last Name:FEARON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MELISSA
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1001 W SENECA ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3342
Mailing Address - Country:US
Mailing Address - Phone:607-277-8020
Mailing Address - Fax:607-277-7961
Practice Address - Street 1:1001 W SENECA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3342
Practice Address - Country:US
Practice Address - Phone:607-277-8020
Practice Address - Fax:607-277-7961
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01236800225100000X
NY0180361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ108454VGNMedicare PIN