Provider Demographics
NPI:1487762258
Name:STORM, ETTA L (NP IN PEDIATRICS)
Entity type:Individual
Prefix:
First Name:ETTA
Middle Name:L
Last Name:STORM
Suffix:
Gender:F
Credentials:NP IN PEDIATRICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 SOUTHWESTERN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1233
Mailing Address - Country:US
Mailing Address - Phone:716-674-1292
Mailing Address - Fax:716-677-4314
Practice Address - Street 1:3085 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1233
Practice Address - Country:US
Practice Address - Phone:716-674-1292
Practice Address - Fax:716-677-4314
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380276-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
9511811OtherINDEPENDENT HEALTH
00026500201OtherUNIVERA HEALTHCARE
000560930001OtherBCBS OF WESTERN NEW YORK