Healthcare Provider Details

I. General information

NPI: 1639725518
Provider Name (Legal Business Name): CORETTA E KILLIKELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 WOLF RD STE 101
ALBANY NY
12205-1221
US

IV. Provider business mailing address

PO BOX 38077
ALBANY NY
12203-8077
US

V. Phone/Fax

Practice location:
  • Phone: 518-334-2254
  • Fax:
Mailing address:
  • Phone: 518-334-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number529069
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: