Healthcare Provider Details

I. General information

NPI: 1982703674
Provider Name (Legal Business Name): KELLY MARIE RAUSCH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 BROADWAY ST
BUFFALO NY
14212-1460
US

IV. Provider business mailing address

1001 MAIN ST FL 5
BUFFALO NY
14203-1009
US

V. Phone/Fax

Practice location:
  • Phone: 716-852-1578
  • Fax: 716-852-5154
Mailing address:
  • Phone: 716-323-0034
  • Fax: 716-323-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number441200
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381753
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: