Provider Demographics
NPI:1336784479
Name:COLT, WENDY SUE
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:COLT
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 1:3810 RT 69
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114
Mailing Address - Country:US
Mailing Address - Phone:315-402-5625
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY504750163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Multi-Specialty