Provider Demographics
NPI:1649027178
Name:FEDONICK, BRYAN MATTHEW (RN)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:MATTHEW
Last Name:FEDONICK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 W MAHONEY RD
Mailing Address - Street 2:
Mailing Address - City:BRASHER FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13613-4213
Mailing Address - Country:US
Mailing Address - Phone:315-250-2700
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2212
Practice Address - Country:US
Practice Address - Phone:315-541-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY772611163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health