Provider Demographics
NPI:1427493683
Name:VOLLES, SUSAN MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:VOLLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:EGNACZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4206 MEDICAL CENTER DR
Mailing Address - Street 2:ST JOSEPH'S CENTER FOR WOUND CARE
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-329-7770
Mailing Address - Fax:315-329-7772
Practice Address - Street 1:4206 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 206
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-329-7770
Practice Address - Fax:315-329-7772
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300837363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400090695Medicare PIN