Healthcare Provider Details

I. General information

NPI: 1053033951
Provider Name (Legal Business Name): KAY NOLLEDO IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 2060 BOX MEDICAL
APO AP
96278-2060
US

IV. Provider business mailing address

UNIT 2060 BOX MEDICAL
APO AP
96278-2060
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-3622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: