Provider Demographics
NPI:1427309814
Name:MAYTUM, EMILY ELIZABETH (FNP)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELIZABETH
Last Name:MAYTUM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:ELIZABETH
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:280 CENTRAL AVE
Mailing Address - Street 2:LOGRASSO HALL STUDENT HEALTH CENTER
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1127
Mailing Address - Country:US
Mailing Address - Phone:716-673-3131
Mailing Address - Fax:716-673-4722
Practice Address - Street 1:280 CENTRAL AVE
Practice Address - Street 2:LOGRASSO HALL STUDENT HEALTH CENTER
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1127
Practice Address - Country:US
Practice Address - Phone:716-673-3131
Practice Address - Fax:716-673-4722
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337466363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400080327Medicare PIN