Healthcare Provider Details

I. General information

NPI: 1144479742
Provider Name (Legal Business Name): JENNIFER CAUDILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 JACKSON ST
ATTICA NY
14011-1202
US

IV. Provider business mailing address

122 MARKET ST
ATTICA NY
14011-1011
US

V. Phone/Fax

Practice location:
  • Phone: 585-861-0399
  • Fax:
Mailing address:
  • Phone: 585-813-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number748088-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: