Provider Demographics
NPI:1285107391
Name:WARD, ANNA AZALIA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:AZALIA
Last Name:WARD
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:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-788-7430
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:1704 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3102
Practice Address - Country:US
Practice Address - Phone:315-788-7430
Practice Address - Fax:315-785-5637
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3372621Medicaid