Healthcare Provider Details

I. General information

NPI: 1649582354
Provider Name (Legal Business Name): KAREN LYNN RAEDER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2010
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH RD
BROOKTONDALE NY
14817-9722
US

IV. Provider business mailing address

300 SOUTH RD. MACORMICK SECURE CENTER
BROOKTONDALE NY
14817
US

V. Phone/Fax

Practice location:
  • Phone: 607-539-7121
  • Fax:
Mailing address:
  • Phone: 607-539-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33 336388
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number33 336388
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: