Provider Demographics
NPI:1528338639
Name:HEAD, ETTA (RN)
Entity type:Individual
Prefix:
First Name:ETTA
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ELMWOOD PL
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-368-6782
Mailing Address - Fax:315-792-1133
Practice Address - Street 1:107 ELMWOOD PL
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4900
Practice Address - Country:US
Practice Address - Phone:315-368-6782
Practice Address - Fax:315-792-1133
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY633748163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse